Morbidity and Mortality Weekly Report
Recommendations and ReportsSeptember 22, 2006 / Vol. 55 / No. RR-14
INSIDE: Continuing Education Examination
department of health and human ser
tment of health and human ser
tment of health and human sertment of health and human ser
tment of health and human services
Centers for Disease Control and PreventionCenters for Disease Control and Prevention
Centers for Disease Control and Prevention Centers for Disease Control and Prevention
Centers for Disease Control and Prevention
Revised Recommendations for HIV Testing
of Adults, Adolescents, and Pregnant Women
in Health-Care Settings
Evolution of HIV Testing Recommendations in Health-Care
Settings and for Pregnant Women ...................................2
Rationale for Screening for HIV Infection...........................4
Rationale for New Recommendations ...............................4
Recommendations for Adults and Adolescents.....................7
Screening for HIV Infection ................................................7
Repeat Screening ..............................................................7
Consent and Pretest Information.......................................7
Diagnostic Testing for HIV Infection ...................................8
Similarities and Differences Between Current and Previous
Recommendations for Adults and Adolescents ................8
Recommendations for Pregnant Women ..............................8
HIV Screening for Pregnant Women and Their Infants .......9
Similarities and Differences Between Current and
Previous Recommendations for Pregnant Women
and Their Infants ...........................................................10
Additional Considerations for HIV Screening ......................10
Clinical Care for HIV-Infected Persons .............................11
Partner Counseling and Referral .....................................11
Special Considerations for Screening Adolescents ...........11
Prevention Services for HIV-Negative Persons .................12
HIV/AIDS Surveillance .....................................................12
Monitoring and Evaluation...............................................12
Primary Prevention and HIV Testing in Nonclinical Settings .12
Regulatory and Legal Considerations ..............................13
Other Guidelines .............................................................13
Centers for Disease Control and Prevention
Julie L. Gerberding, MD, MPH
Tanja Popovic, MD, PhD
(Acting) Chief Science Officer
James W. Stephens, PhD
(Acting) Associate Director for Science
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Director, National Center for Health Marketing
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(Acting) Director, Division of Health Information Dissemination (Proposed)
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(Acting) Editor, MMWR Series
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Suggested Citation: Centers for Disease Control and Prevention.
[Title]. MMWR 2006;55(No. RR-14):[inclusive page numbers].
Vol. 55 / RR-14Recommendations and Reports1
The material in this report originated in the National Center for
HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed),
Kevin A. Fenton, MD, PhD, Director; and the Division of HIV/
AIDS Prevention, Timothy D. Mastro, MD, (Acting) Director.
Corresponding preparer: Bernard M. Branson, MD, Division of HIV/
AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis,
STD, and TB Prevention (proposed), 1600 Clifton Road, N.E.,
MS D-21, Atlanta, GA 30333. Telephone: 404-639-0900; Fax: 404-
639-0897; E-mail: email@example.com.
Revised Recommendations for HIV Testing
of Adults, Adolescents, and Pregnant Women
in Health-Care Settings
Bernard M. Branson, MD1
H. Hunter Handsfield, MD2
Margaret A. Lampe, MPH1
Robert S. Janssen, MD1
Allan W. Taylor, MD1
Sheryl B. Lyss, MD1
Jill E. Clark, MPH3
1Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed)
2Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed) and University of Washington, Seattle, Washington
3Northrup Grumman Information Technology (contractor with CDC)
These recommendations for human immunodeficiency virus (HIV) testing are intended for all health-care providers in the
public and private sectors, including those working in hospital emergency departments, urgent care clinics, inpatient services,
substance abuse treatment clinics, public health clinics, community clinics, correctional health-care facilities, and primary care
settings. The recommendations address HIV testing in health-care settings only. They do not modify existing guidelines concerning
HIV counseling, testing, and referral for persons at high risk for HIV who seek or receive HIV testing in nonclinical settings (e.g.,
community-based organizations, outreach settings, or mobile vans). The objectives of these recommendations are to increase
HIV screening of patients, including pregnant women, in health-care settings; foster earlier detection of HIV infection;
identify and counsel persons with unrecognized HIV infection and link them to clinical and prevention services; and further
reduce perinatal transmission of HIV in the United States. These revised recommendations update previous recommendations for
HIV testing in health-care settings and for screening of pregnant women (CDC. Recommendations for HIV testing services
for inpatients and outpatients in acute-care hospital settings. MMWR 1993;42[No. RR-2]:1–10; CDC. Revised guide-
lines for HIV counseling, testing, and referral. MMWR 2001;50[No. RR-19]:1–62; and CDC. Revised recommenda-
tions for HIV screening of pregnant women. MMWR 2001;50[No. RR-19]:63–85).
Major revisions from previously published guidelines are as follows:
For patients in all health-care settings
• HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be
performed unless the patient declines (opt-out screening).
• Persons at high risk for HIV infection should be screened for HIV at least annually.
• Separate written consent for HIV testing should not be required; general consent for medical care should be considered
sufficient to encompass consent for HIV testing.
• Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in
For pregnant women
• HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women.
• HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines
• Separate written consent for HIV testing should not
be required; general consent for medical care should
be considered sufficient to encompass consent for HIV
• Repeat screening in the third trimester is recommended
in certain jurisdictions with elevated rates of HIV
infection among pregnant women.
2 MMWR September 22, 2006
Human immunodeficiency virus (HIV) infection and
acquired immunodeficiency syndrome (AIDS) remain lead-
ing causes of illness and death in the United States. As of
December 2004, an estimated 944,306 persons had received
a diagnosis of AIDS, and of these, 529,113 (56%) had died
(1). The annual number of AIDS cases and deaths declined
substantially after 1994 but stabilized during 1999–2004 (1).
However, since 1994, the annual number of cases among
blacks, members of other racial/ethnic minority populations,
and persons exposed through heterosexual contact has
increased. The number of children reported with AIDS
attributed to perinatal HIV transmission peaked at 945 in
1992 and declined 95% to 48 in 2004 (1), primarily because
of the identification of HIV-infected pregnant women and
the effectiveness of antiretroviral prophylaxis in reducing
mother-to-child transmission of HIV (2).
By 2002, an estimated 38%–44% of all adults in the United
States had been tested for HIV; 16–22 million persons aged
18–64 years are tested annually for HIV (3). However, at the
end of 2003, of the approximately 1.0–1.2 million persons
estimated to be living with HIV in the United States, an esti-
mated one quarter (252,000–312,000 persons) were unaware
of their infection and therefore unable to benefit from clinical
care to reduce morbidity and mortality (4). A number of these
persons are likely to have transmitted HIV unknowingly (5).
Treatment has improved survival rates dramatically, espe-
cially since the introduction of highly active antiretroviral
therapy (HAART) in 1995 (6). However, progress in effect-
ing earlier diagnosis has been insufficient. During 1990–1992,
the proportion of persons who first tested positive for HIV
<1 year before receiving a diagnosis of AIDS was 51% (7);
during 1993–2004, this proportion declined only modestly,
to 39% in 2004 (1). Persons tested late in the course of their
infection were more likely to be black or Hispanic and to have
been exposed through heterosexual contact; 87% received their
first positive HIV test result at an acute or referral medical
care setting, and 65% were tested for HIV antibody because
of illness (8).
These recommendations update previous recommendations
for HIV testing in health-care settings (9,10) and for screen-
ing of pregnant women (11). The objectives of these recom-
mendations are to increase HIV screening of patients,
including pregnant women, in health-care settings; foster
earlier detection of HIV infection; identify and counsel
persons with unrecognized HIV infection and link them to
clinical and prevention services; and further reduce perinatal
transmission of HIV in the United States.
Single copies of this report are available free of charge
from CDC’s National Prevention Information Network,
telephone 800-458-5231 (Mondays–Fridays, 9:00 a.m.–
8:00 p.m. ET).
Diagnostic testing. Performing an HIV test for persons
with clinical signs or symptoms consistent with HIV infection.
Screening. Performing an HIV test for all persons in a
defined population (12).
Targeted testing. Performing an HIV test for subpopula-
tions of persons at higher risk, typically defined on the
basis of behavior, clinical, or demographic characteristics (9).
Informed consent. A process of communication between
patient and provider through which an informed patient can
choose whether to undergo HIV testing or decline to do so.
Elements of informed consent typically include providing oral
or written information regarding HIV, the risks and benefits
of testing, the implications of HIV test results, how test
results will be communicated, and the opportunity to ask
Opt-out screening. Performing HIV screening after
notifying the patient that 1) the test will be performed and
2) the patient may elect to decline or defer testing. Assent
is inferred unless the patient declines testing.
HIV-prevention counseling. An interactive process of
assessing risk, recognizing specific behaviors that increase the
risk for acquiring or transmitting HIV, and developing a plan
to take specific steps to reduce risks (13).
Evolution of HIV Testing
Recommendations in Health-Care
Settings and for Pregnant Women
In 1985, when HIV testing first became available, the main
goal of such testing was to protect the blood supply. Alterna-
tive test sites were established to deter persons from using blood
bank testing to learn their HIV status. At that time, profes-
sional opinion was divided regarding the value of HIV testing
and whether HIV testing should be encouraged because
no consensus existed regarding whether a positive test pre-
dicted transmission to sex partners or from mother to
infant (14). No effective treatment existed, and counseling
was designed in part to ensure that persons tested were
aware that the meaning of positive test results was uncertain.
Vol. 55 / RR-14 Recommendations and Reports3
During the next 2 years, the implications of positive HIV
serology became evident, and in 1987, the United States
Public Health Service (USPHS) issued guidelines making
HIV counseling and testing a priority as a prevention strat-
egy for persons most likely to be infected or who practiced
high-risk behaviors and recommended routine testing of
all persons seeking treatment for STDs, regardless of health-
care setting (15). “Routine” was defined as a policy to pro-
vide these services to all clients after informing them that
testing would be conducted (15).
In 1993, CDC recommendations for voluntary HIV
counseling and testing were extended to include hospital-
ized patients and persons obtaining health care as outpa-
tients in acute-care hospital settings, including emergency
departments (EDs) (10). Hospitals with HIV
seroprevalence rates of >1% or AIDS diagnosis rates of >1
per 1,000 discharges were encouraged to adopt a policy of
offering voluntary HIV counseling and testing routinely to
all patients aged 15–54 years. Health-care providers in
acute-care settings were encouraged to structure counsel-
ing and testing procedures to facilitate confidential, volun-
tary participation and to include basic information
regarding the medical implications of the test, the option
to receive more information, and documentation of in-
formed consent (10). In 1994, guidelines for counseling
and testing persons with high-risk behaviors specified pre-
vention counseling to develop specific prevention goals and
strategies for each person (client-centered counseling) (16).
In 1995, after perinatal transmission of HIV was demon-
strated to be substantially reduced by administration of
zidovudine to HIV-infected pregnant women and their
newborns, USPHS recommended that all pregnant women
be counseled and encouraged to undergo voluntary testing
for HIV (17,18).
In 2001, CDC modified the recommendations for preg-
nant women to emphasize HIV screening as a routine part of
prenatal care, simplification of the testing process so pretest
counseling would not pose a barrier, and flexibility of the con-
sent process to allow multiple types of informed consent (11).
In addition, the 2001 recommendations for HIV testing in
health-care settings were extended to include multiple addi-
tional clinical venues in both private and public health-care
sectors, encouraging providers to make HIV counseling and
testing more accessible and acknowledging their need for flex-
ibility (9). CDC recommended that HIV testing be offered
routinely to all patients in high HIV-prevalence health-care
settings. In low prevalence settings, in which the majority of
clients are at minimal risk, targeted HIV testing on the basis
of risk screening was considered more feasible for identifying
limited numbers of HIV-infected persons (9).
In 2003, CDC introduced the initiative Advancing HIV
Prevention: New Strategies for a Changing Epidemic (19).
Two key strategies of this initiative are 1) to make HIV testing
a routine part of medical care on the same voluntary basis
as other diagnostic and screening tests and 2) to reduce
perinatal transmission of HIV further by universal testing
of all pregnant women and by using rapid tests during la-
bor and delivery or postpartum if the mother was not
screened prenatally (19). In its technical guidance, CDC
acknowledged that prevention counseling is desirable for
all persons at risk for HIV but recognized that such coun-
seling might not be appropriate or feasible in all settings
(20). Because time constraints or discomfort with discuss-
ing their patients’ risk behaviors caused some providers to
perceive requirements for prevention counseling and writ-
ten informed consent as a barrier (12,21–23), the initia-
tive advocated streamlined approaches.
In March 2004, CDC convened a meeting of health-care
providers, representatives from professional associations, and
local health officials to obtain advice concerning how best to
expand HIV testing, especially in high-volume, high-
prevalence acute-care settings. Consultants recommended sim-
plifying the HIV screening process to make it more feasible
and less costly and advocated more frequent diagnostic test-
ing of patients with symptoms. In April 2005, CDC initiated
a comprehensive review of the literature regarding HIV test-
ing in health-care settings and, on the basis of published
evidence and lessons learned from CDC-sponsored demon-
stration projects of HIV screening in health-care facilities,
began to prepare recommendations to implement these strat-
egies. In August 2005, CDC invited health-care providers,
representatives from public health agencies and community
organizations, and persons living with HIV to review an out-
line of proposed recommendations. In November 2005, CDC
convened a meeting of researchers, representatives of profes-
sional health-care provider organizations, clinicians, persons
living with HIV, and representatives from community orga-
nizations and agencies overseeing care of HIV-infected per-
sons to review CDC’s proposed recommendations. Before
final revision of these recommendations, CDC described
the proposals at national meetings of researchers and health-
care providers and, in March 2006, solicited peer review
by health-care professionals, in compliance with require-
ments of the Office of Management and Budget for influ-
ential scientific assessments, and invited comment from
multiple professional and community organizations. The
final recommendations were further refined on the basis of
comments from these constituents.
4 MMWRSeptember 22, 2006
Rationale for Routine Screening
for HIV Infection
Previous CDC and U.S. Preventive Services Task Force
guidelines for HIV testing recommended routine counsel-
ing and testing for persons at high risk for HIV and for
those in acute-care settings in which HIV prevalence was
>1% (9,10,24). These guidelines proved difficult to imple-
ment because 1) the cost of HIV screening often is not
reimbursed, 2) providers in busy health-care settings often
lack the time necessary to conduct risk assessments and
might perceive counseling requirements as a barrier to test-
ing, and 3) explicit information regarding HIV prevalence
typically is not available to guide selection of specific
settings for screening (25–29).
These revised CDC recommendations advocate routine
voluntary HIV screening as a normal part of medical prac-
tice, similar to screening for other treatable conditions.
Screening is a basic public health tool used to identify
unrecognized health conditions so treatment can be offered
before symptoms develop and, for communicable diseases,
so interventions can be implemented to reduce the likeli-
hood of continued transmission (30).
HIV infection is consistent with all generally accepted cri-
teria that justify screening: 1) HIV infection is a serious
health disorder that can be diagnosed before symptoms
develop; 2) HIV can be detected by reliable, inexpensive, and
noninvasive screening tests; 3) infected patients have years of
life to gain if treatment is initiated early, before symptoms
develop; and 4) the costs of screening are reasonable in rela-
tion to the anticipated benefits (30). Among pregnant women,
screening has proven substantially more effective than risk-
based testing for detecting unsuspected maternal HIV infec-
tion and preventing perinatal transmission (31–33).
Rationale for New Recommendations
Often, persons with HIV infection visit health-care settings
(e.g., hospitals, acute-care clinics, and sexually transmitted
disease [STD] clinics) years before receiving a diagnosis but
are not tested for HIV (34–36). Since the 1980s, the demo-
graphics of the HIV/AIDS epidemic in the United States have
changed; increasing proportions of infected persons are aged
<20 years, women, members of racial or ethnic minority popu-
lations, persons who reside outside metropolitan areas, and
heterosexual men and women who frequently are unaware
that they are at risk for HIV (37). As a result, the effectiveness
of using risk-based testing to identify HIV-infected persons
has diminished (34,35,38,39).
Prevention strategies that incorporate universal HIV screen-
ing have been highly effective. For example, screening blood
donors for HIV has nearly eliminated transfusion-associ-
ated HIV infection in the United States (40). In addition,
incidence of pediatric HIV/AIDS in the United States has
declined substantially since the 1990s, when prevention strat-
egies began to include specific recommendations for routine
HIV testing of pregnant women (18,41). Perinatal transmis-
sion rates can be reduced to <2% with universal screening of
pregnant women in combination with prophylactic admin-
istration of antiretroviral drugs (42,43), scheduled cesar-
ean delivery when indicated (44,45), and avoidance of
breast feeding (46).
These successes contrast with a relative lack of progress
in preventing sexual transmission of HIV, for which screen-
ing rarely is performed. Declines in HIV incidence
observed in the early 1990s have leveled and might even
have reversed in certain populations in recent years (47,48).
Since 1998, the estimated number of new infections has
remained stable at approximately 40,000 annually (49).
In 2001, the Institute of Medicine (IOM) emphasized pre-
vention services for HIV-infected persons and recommended
policies for diagnosing HIV infections earlier to increase
the number of HIV-infected persons who were aware of
their infections and who were offered clinical and preven-
tion services (37). The majority of persons who are aware
of their HIV infections substantially reduce sexual behav-
iors that might transmit HIV after they become aware they
are infected (5). In a meta-analysis of findings from eight
studies, the prevalence of unprotected anal or vaginal
intercourse with uninfected partners was on average 68%
lower for HIV-infected persons who were aware of their
status than it was for HIV-infected persons who were
unaware of their status (5). To increase diagnosis of HIV
infection, destigmatize the testing process, link clinical care
with prevention, and ensure immediate access to clinical
care for persons with newly identified HIV infection, IOM
and other health-care professionals with expertise
(25,37,50,51) have encouraged adoption of routine HIV
testing in all health-care settings.
Routine prenatal HIV testing with streamlined counseling
and consent procedures has increased the number of preg-
nant women tested substantially (52). By contrast, the num-
ber of persons at risk for HIV infection who are screened in
acute-care settings remains low, despite repeated recommen-
dations in support of routine risk-based testing in health-care
settings (9,10,15,34,53,54). In a survey of 154 health-care
providers in 10 hospital EDs, providers reported caring for an
average of 13 patients per week suspected to have STDs, but
only 10% of these providers encouraged such patients to be
tested for HIV while they were in the ED (54). Another 35%
referred patients to confidential HIV testing sites in the
Vol. 55 / RR-14 Recommendations and Reports5
community; however, such referrals have proven ineffective
because of poor compliance by patients (55). Reasons cited
for not offering HIV testing in the ED included lack of
established mechanisms to ensure follow-up (51%), lack
of the certification perceived as necessary to provide coun-
seling (45%), and belief that the testing process was too
time-consuming (19%) (54).
With the institution of HIV screening in certain hospi-
tals and EDs, the percentage of patients who test positive
(2%–7%) often has exceeded that observed nationally at
publicly funded HIV counseling and testing sites (1.5%) and
STD clinics (2%) serving persons at high risk for HIV (53,56–
59). Because patients rarely were seeking testing when screen-
ing was offered at these hospitals, HIV infections often were
identified earlier than they might otherwise have been (29).
Targeted testing programs also have been implemented in
acute-care settings; nearly two thirds of patients in these set-
tings accept testing, but because risk assessment and preven-
tion counseling are time-consuming, only a limited
proportion of eligible patients can be tested (29). Targeted
testing on the basis of risk behaviors fails to identify a sub-
stantial number of persons who are HIV infected (34,35,39).
A substantial number of persons, including persons with
HIV infection, do not perceive themselves to be at risk for
HIV or do not disclose their risks (53,56,59). Routine HIV
testing reduces the stigma associated with testing that
requires assessment of risk behaviors (60–63). More
patients accept recommended HIV testing when it is
offered routinely to everyone, without a risk assessment
In 1999, to increase the proportion of women tested for
HIV, IOM recommended 1) adopting a national policy of
universal HIV testing of pregnant women with patient notifi-
cation (opt-out screening) as a routine component of prena-
tal care, 2) eliminating requirements for extensive pretest
counseling while requiring provision of basic information
regarding HIV, and 3) not requiring explicit written consent
to be tested for HIV (12). Subsequent studies have indicated
that these policies, as proposed by IOM and other profes-
sional organizations (12,64,65), reflect an ethical balance
among public health goals, justice, and individual rights
(66,67). Rates of HIV screening are consistently higher at
settings that provide prenatal and STD services using opt-
out screening than at opt-in programs, which require pre-
test counseling and explicit written consent (52,68–74).
Pregnant women express less anxiety with opt-out HIV
screening and do not find it difficult to decline a test (68,74).
In 2006, approximately 65% of U.S. adults surveyed
concurred that HIV testing should be treated the same as
screening for any other disease, without special procedures
such as written permission from the patient (75).
Adolescents aged 13–19 years represent new cohorts of
persons at risk, and prevention efforts need to be repeated
for each succeeding generation of young persons (63). The
2005 Youth Risk Behavior Survey indicated that 47% of
high school students reported that they had had sexual
intercourse at least once, and 37% of sexually active stu-
dents had not used a condom during their most recent act
of sexual intercourse (76). More than half of all HIV-
infected adolescents are estimated not to have been tested
and are unaware of their infection (77,78). Among young
(aged 18–24 years) men who have sex with men (MSM)
surveyed during 2004–2005 in five U.S. cities, 14% were
infected with HIV; 79% of these HIV-infected MSM were
unaware of their infection (56). The American Academy of
Pediatrics recommends that clinicians obtain information
from adolescent patients regarding their sexual activity and
inform them how to prevent HIV infection (79). Evidence
indicates that adolescents prefer to receive this information
from their health-care providers rather than from their par-
ents, teachers, or friends (80). However, fewer than half of
clinicians provide such guidance (81). Health-care provid-
ers’ recommendations also influence adolescents’ decision
to be tested. Among reasons for HIV testing provided by
528 adolescents who had primary care providers, 58% cited
their provider’s recommendation as their reason for testing
The U.S. Preventive Services Task Force recently recom-
mended that clinicians screen for HIV all adults and adoles-
cents at increased risk for HIV, on the basis that when HIV is
diagnosed early, appropriately timed interventions, particu-
larly HAART, can lead to improved health outcomes, includ-
ing slower clinical progression and reduced mortality (24).
The Task Force also recommended screening all pregnant
women, regardless of risk, but made no recommendation for
or against routinely screening asymptomatic adults and ado-
lescents with no identifiable risk factors for HIV. The Task
Force concluded that such screening would detect additional
patients with HIV, but the overall number would be limited,
and the potential benefits did not clearly outweigh the bur-
den on primary care practices or the potential harms of a gen-
eral HIV screening program (24,83). In making these
recommendations, the Task Force considered how many
patients would need to be screened to prevent one clinical
progression or death during the 3-year period after screening.
On the basis of evidence available for its review, the Task Force
was unable to calculate benefits attributable to the prevention
of secondary HIV transmission to partners (84). However, a
6 MMWR September 22, 2006
recent meta-analysis indicated that HIV-infected persons
reduced high-risk behavior substantially when they became
aware of their infection (5). Because viral load is the chief
biologic predictor of HIV transmission (85), reduction in
viral load through timely initiation of HAART might
reduce transmission, even for HIV-infected patients who do
not change their risk behavior (86). Estimated transmission is
3.5 times higher among persons who are unaware of their
infection than among persons who are aware of their infec-
tion and contributes disproportionately to the number of new
HIV infections each year in the United States (87). In theory,
new sexual HIV infections could be reduced >30% per year if
all infected persons could learn their HIV status and adopt
changes in behavior similar to those adopted by persons
already aware of their infection (87).
Recent studies demonstrate that voluntary HIV screen-
ing is cost-effective even in health-care settings in which
HIV prevalence is low (26,27,86). In populations for
which prevalence of undiagnosed HIV infection is >0.1%,
HIV screening is as cost-effective as other established screen-
ing programs for chronic diseases (e.g., hypertension,
colon cancer, and breast cancer) (27,86). Because of the
substantial survival advantage resulting from earlier diag-
nosis of HIV infection when therapy can be initiated
before severe immunologic compromise occurs, screening
reaches conventional benchmarks for cost-effectiveness even
before including the important public health benefit from
reduced transmission to sex partners (86).
Linking patients who have received a diagnosis of HIV
infection to prevention and care is essential. HIV screening
without such linkage confers little or no benefit to the patient.
Although moving patients into care incurs substantial costs,
it also triggers sufficient survival benefits that justify the addi-
tional costs. Even if only a limited fraction of patients who
receive HIV-positive results are linked to care, the survival
benefits per dollar spent on screening represent good
comparative value (26,27,88).
The benefit of providing prevention counseling in conjunc-
tion with HIV testing is less clear. HIV counseling with test-
ing has been demonstrated to be an effective intervention for
HIV-infected participants, who increased their safer behav-
iors and decreased their risk behaviors; HIV counseling and
testing as implemented in the studies had little effect on HIV-
negative participants (89). However, randomized controlled
trials have demonstrated that the nature and duration of pre-
vention counseling might influence its effectiveness (90,91).
Carefully controlled, theory-based prevention counseling in
STD clinics has helped HIV-negative participants reduce their
risk behaviors compared with participants who received only
a didactic prevention message from health-care providers (90).
A more intensive intervention among HIV-negative MSM
at high risk, consisting of 10 theory-based individual coun-
seling sessions followed by maintenance sessions every
3 months, resulted in reductions in unprotected sex with
partners who were HIV infected or of unknown status, com-
pared with MSM who received structured prevention coun-
seling only twice yearly (91).
Timely access to diagnostic HIV test results also improves
health outcomes. Diagnostic testing in health-care settings
continues to be the mechanism by which nearly half of new
HIV infections are identified. During 2000–2003, of persons
reported with HIV/AIDS who were interviewed in 16 states,
44% were tested for HIV because of illness (8). Compared
with HIV testing after patients were admitted to the hospital,
expedited diagnosis by rapid HIV testing in the ED before
admission led to shorter hospital stays, increased the number
of patients aware of their HIV status before discharge, and
improved entry into outpatient care (92). However, at least
28 states have laws or regulations that limit health-care pro-
viders’ ability to order diagnostic testing for HIV infection if
the patient is unable to give consent for HIV testing, even
when the test results are likely to alter the patient’s diagnostic
or therapeutic management (93).
Of the 40,000 persons who acquire HIV infection each year,
an estimated 40%–90% will experience symptoms of acute
HIV infection (94–96), and a substantial number will seek
medical care. However, acute HIV infection often is not rec-
ognized by primary care clinicians because the symptoms
resemble those of influenza, infectious mononucleosis, and
other viral illnesses (97). Acute HIV infection can be diag-
nosed by detecting HIV RNA in plasma from persons with a
negative or indeterminate HIV antibody test. One study based
on national ambulatory medical care surveys estimated that
the prevalence of acute HIV infection was 0.5%–0.7% among
ambulatory patients who sought care for fever or rash (98).
Although the long-term benefit of HAART during acute HIV
infection has not been established conclusively (99), identify-
ing primary HIV infection can reduce the spread of HIV that
might otherwise occur during the acute phase of HIV disease
Perinatal HIV transmission continues to occur, primarily
among women who lack prenatal care or who were not
offered voluntary HIV counseling and testing during preg-
nancy. A substantial proportion of the estimated 144–236
perinatal HIV infections in the United States each year can be
attributed to the lack of timely HIV testing and treatment of
pregnant women (102). Multiple barriers to HIV testing have
been identified, including language barriers; late entry into
prenatal care; health-care providers’ perceptions that their
patients are at low risk for HIV; lack of time for counseling
Vol. 55 / RR-14 Recommendations and Reports7
and testing, particularly for rapid testing during labor and
delivery; and state regulations requiring counseling and sepa-
rate informed consent (103). A survey of 653 obstetrical pro-
viders in North Carolina suggested that not all health-care
providers embrace universal testing of pregnant women; the
strength with which providers recommended prenatal testing
to their patients and the numbers of women tested
depended largely on the providers’ perception of the patients’
risk behaviors (21). Data confirm that testing rates are higher
when HIV tests are included in the standard panel of screen-
ing tests for all pregnant women (52,69,104). Women also
are much more likely to be tested if they perceive that their
health-care provider strongly recommends HIV testing (105).
As universal prenatal screening has become more widespread,
an increasing proportion of pregnant women who had undi-
agnosed HIV infection at the time of delivery were found to
have seroconverted during pregnancy (106). A second HIV
test during the third trimester for women in settings with
elevated HIV incidence (>17 cases per 100,000 person-years)
is cost-effective and might result in substantial reductions in
mother-to-child HIV transmission (107).
Every perinatal HIV transmission is a sentinel health event,
signaling either a missed opportunity for prevention or, more
rarely, a failure of interventions to prevent perinatal transmis-
sion. When these infections occur, they underscore the need
for improved strategies to ensure that all pregnant women
undergo HIV testing and, if found to be HIV positive,
receive proper interventions to reduce their transmission risk
and safeguard their health and the health of their infants.
Recommendations for Adults
CDC recommends that diagnostic HIV testing and opt-
out HIV screening be a part of routine clinical care in all
health-care settings while also preserving the patient’s op-
tion to decline HIV testing and ensuring a provider-pa-
tient relationship conducive to optimal clinical and
preventive care. The recommendations are intended for
providers in all health-care settings, including hospital EDs,
urgent-care clinics, inpatient services, STD clinics or other
venues offering clinical STD services, tuberculosis (TB) clin-
ics, substance abuse treatment clinics, other public health
clinics, community clinics, correctional health-care facili-
ties, and primary care settings. The guidelines address HIV
testing in health-care settings only; they do not modify
existing guidelines concerning HIV counseling, testing, and
referral for persons at high risk for HIV who seek or receive
HIV testing in nonclinical settings (e.g., community-
based organizations, outreach settings, or mobile vans) (9).
Screening for HIV Infection
• In all health-care settings, screening for HIV infection
should be performed routinely for all patients aged
13–64 years. Health-care providers should initiate
screening unless prevalence of undiagnosed HIV infec-
tion in their patients has been documented to be
<0.1%. In the absence of existing data for HIV preva-
lence, health-care providers should initiate voluntary
HIV screening until they establish that the diagnostic
yield is <1 per 1,000 patients screened, at which point
such screening is no longer warranted.
• All patients initiating treatment for TB should be screened
routinely for HIV infection (108).
• All patients seeking treatment for STDs, including all
patients attending STD clinics, should be screened
routinely for HIV during each visit for a new complaint,
regardless of whether the patient is known or suspected
to have specific behavior risks for HIV infection.
• Health-care providers should subsequently test all per-
sons likely to be at high risk for HIV at least annually.
Persons likely to be at high risk include injection-drug
users and their sex partners, persons who exchange sex
for money or drugs, sex partners of HIV-infected per-
sons, and MSM or heterosexual persons who themselves
or whose sex partners have had more than one sex
partner since their most recent HIV test.
• Health-care providers should encourage patients and their
prospective sex partners to be tested before initiating a
new sexual relationship.
• Repeat screening of persons not likely to be at high risk
for HIV should be performed on the basis of clinical
• Unless recent HIV test results are immediately avail-
able, any person whose blood or body fluid is the source
of an occupational exposure for a health-care provider
should be informed of the incident and tested for HIV
infection at the time the exposure occurs.
Consent and Pretest Information
• Screening should be voluntary and undertaken only with
the patient’s knowledge and understanding that HIV
testing is planned.
• Patients should be informed orally or in writing that
HIV testing will be performed unless they decline (opt-
out screening). Oral or written information should
include an explanation of HIV infection and the
8 MMWRSeptember 22, 2006
meanings of positive and negative test results, and the
patient should be offered an opportunity to ask ques-
tions and to decline testing. With such notification,
consent for HIV screening should be incorporated into
the patient’s general informed consent for medical care
on the same basis as are other screening or diagnostic
tests; a separate consent form for HIV testing is not
• Easily understood informational materials should be
made available in the languages of the commonly
encountered populations within the service area. The
competence of interpreters and bilingual staff to
provide language assistance to patients with limited
English proficiency must be ensured.
• If a patient declines an HIV test, this decision should be
documented in the medical record.
Diagnostic Testing for HIV Infection
• All patients with signs or symptoms consistent with HIV
infection or an opportunistic illness characteristic of AIDS
should be tested for HIV.
• Clinicians should maintain a high level of suspicion for
acute HIV infection in all patients who have a compat-
ible clinical syndrome and who report recent high-risk
behavior. When acute retroviral syndrome is a possibility,
a plasma RNA test should be used in conjunction with
an HIV antibody test to diagnose acute HIV infection
• Patients or persons responsible for the patient’s care should
be notified orally that testing is planned, advised of the
indication for testing and the implications of positive and
negative test results, and offered an opportunity to ask
questions and to decline testing. With such notification,
the patient’s general consent for medical care is consid-
ered sufficient for diagnostic HIV testing.
Similarities and Differences Between
Current and Previous
Recommendations for Adults
Aspects of these recommendations that remain unchanged
from previous recommendations are as follows:
• HIV testing must be voluntary and free from coercion.
Patients must not be tested without their knowledge.
• HIV testing is recommended and should be routine for
persons attending STD clinics and those seeking treat-
ment for STDs in other clinical settings.
• Access to clinical care, prevention counseling, and sup-
port services is essential for persons with positive HIV
Aspects of these recommendations that differ from previ-
ous recommendations are as follows:
• Screening after notifying the patient that an HIV test
will be performed unless the patient declines (opt-out
screening) is recommended in all health-care settings.
Specific signed consent for HIV testing should not be
required. General informed consent for medical care
should be considered sufficient to encompass informed
consent for HIV testing.
• Persons at high risk for HIV should be screened for HIV
at least annually.
• HIV test results should be provided in the same manner
as results of other diagnostic or screening tests.
• Prevention counseling should not be required as a part
of HIV screening programs in health-care settings. Pre-
vention counseling is strongly encouraged for persons
at high risk for HIV in settings in which risk behaviors
are assessed routinely (e.g., STD clinics) but should
not have to be linked to HIV testing.
• HIV diagnostic testing or screening to detect HIV infec-
tion earlier should be considered distinct from HIV coun-
seling and testing conducted primarily as a prevention
intervention for uninfected persons at high risk.
These guidelines reiterate the recommendation for univer-
sal HIV screening early in pregnancy but advise simplifying
the screening process to maximize opportunities for women
to learn their HIV status during pregnancy, preserving the
woman’s option to decline HIV testing, and ensuring a
provider-patient relationship conducive to optimal clinical and
preventive care. All women should receive HIV screening con-
sistent with the recommendations for adults and adolescents.
HIV screening should be a routine component of preconcep-
tion care, maximizing opportunities for all women to know
their HIV status before conception (109). In addition, screen-
ing early in pregnancy enables HIV-infected women and their
infants to benefit from appropriate and timely interventions
(e.g., antiretroviral medications , scheduled cesarean
delivery , and avoidance of breastfeeding* ). These
* To eliminate the risk for postnatal transmission, HIV-infected women in
the United States should not breastfeed. Support services for use of appropriate
breast milk substitutes should be provided when necessary. In international
settings, UNAIDS and World Health Organization recommendations for
HIV and breastfeeding should be followed (46).
Vol. 55 / RR-14 Recommendations and Reports9
†A second HIV test in the third trimester is as cost-effective as other common
health interventions when HIV incidence among women of childbearing
age is >17 HIV cases per 100,000 person-years (107). In 2004, in jurisdictions
with available data on HIV case rates, a rate of 17 new HIV diagnoses per
year per 100,000 women aged 15–45 years was associated with an AIDS
case rate of at least nine AIDS diagnoses per year per 100,000 women aged
15–45 years (CDC, unpublished data, 2005). As of 2004, the jurisdictions
listed above exceeded these thresholds. The list of specific jurisdictions where
a second test in the third trimester is recommended will be updated
periodically based on surveillance data.
recommendations are intended for clinicians who provide
care to pregnant women and newborns and for health policy
makers who have responsibility for these populations.
HIV Screening for Pregnant Women and
Universal Opt-Out Screening
• All pregnant women in the United States should be
screened for HIV infection.
• Screening should occur after a woman is notified that HIV
screening is recommended for all pregnant patients and
that she will receive an HIV test as part of the routine
panel of prenatal tests unless she declines (opt-out
• HIV testing must be voluntary and free from coercion.
No woman should be tested without her knowledge.
• Pregnant women should receive oral or written informa-
tion that includes an explanation of HIV infection, a
description of interventions that can reduce HIV trans-
mission from mother to infant, and the meanings of posi-
tive and negative test results and should be offered an
opportunity to ask questions and to decline testing.
• No additional process or written documentation of
informed consent beyond what is required for other
routine prenatal tests should be required for HIV testing.
• If a patient declines an HIV test, this decision should be
documented in the medical record.
Addressing Reasons for Declining Testing
• Providers should discuss and address reasons for declin-
ing an HIV test (e.g., lack of perceived risk; fear of the
disease; and concerns regarding partner violence or
potential stigma or discrimination).
• Women who decline an HIV test because they have had a
previous negative test result should be informed of the
importance of retesting during each pregnancy.
• Logistical reasons for not testing (e.g., scheduling) should
• Certain women who initially decline an HIV test might
accept at a later date, especially if their concerns are dis-
cussed. Certain women will continue to decline testing,
and their decisions should be respected and documented
in the medical record.
Timing of HIV Testing
• To promote informed and timely therapeutic decisions,
health-care providers should test women for HIV as early
as possible during each pregnancy. Women who
decline the test early in prenatal care should be
encouraged to be tested at a subsequent visit.
• A second HIV test during the third trimester, prefer-
ably <36 weeks of gestation, is cost-effective even in
areas of low HIV prevalence and may be considered for
all pregnant women. A second HIV test during the
third trimester is recommended for women who meet
one or more of the following criteria:
— Women who receive health care in jurisdictions with
elevated incidence of HIV or AIDS among women
aged 15–45 years. In 2004, these jurisdictions included
Alabama, Connecticut, Delaware, the District of
Columbia, Florida, Georgia, Illinois, Louisiana,
Maryland, Massachusetts, Mississippi, Nevada, New
Jersey, New York, North Carolina, Pennsylvania,
Puerto Rico, Rhode Island, South Carolina,
Tennessee, Texas, and Virginia.†
— Women who receive health care in facilities in which
prenatal screening identifies at least one HIV-infected
pregnant woman per 1,000 women screened.
— Women who are known to be at high risk for acquir-
ing HIV (e.g., injection-drug users and their sex part-
ners, women who exchange sex for money or drugs,
women who are sex partners of HIV-infected persons,
and women who have had a new or more than one sex
partner during this pregnancy).
— Women who have signs or symptoms consistent with
acute HIV infection. When acute retroviral syndrome
is a possibility, a plasma RNA test should be used in
conjunction with an HIV antibody test to diagnose
acute HIV infection (96).
Rapid Testing During Labor
• Any woman with undocumented HIV status at the time
of labor should be screened with a rapid HIV test unless
she declines (opt-out screening).
• Reasons for declining a rapid test should be explored (see
Addressing Reasons for Declining Testing).
• Immediate initiation of appropriate antiretroviral pro-
phylaxis (42) should be recommended to women on
the basis of a reactive rapid test result without waiting
for the result of a confirmatory test.
10 MMWR September 22, 2006
• When a woman’s HIV status is still unknown at the
time of delivery, she should be screened immediately
postpartum with a rapid HIV test unless she declines
• When the mother’s HIV status is unknown postpartum,
rapid testing of the newborn as soon as possible after birth
is recommended so antiretroviral prophylaxis can be
offered to HIV-exposed infants. Women should be
informed that identifying HIV antibodies in the new-
born indicates that the mother is infected.
• For infants whose HIV exposure status is unknown and
who are in foster care, the person legally authorized to
provide consent should be informed that rapid HIV test-
ing is recommended for infants whose biologic mothers
have not been tested.
• The benefits of neonatal antiretroviral prophylaxis are best
realized when it is initiated <12 hours after birth (110).
• Whenever possible, uncertainties regarding laboratory test
results indicating HIV infection status should be resolved
before final decisions are made regarding reproductive
options, antiretroviral therapy, cesarean delivery, or other
• If the confirmatory test result is not available before
delivery, immediate initiation of appropriate
antiretroviral prophylaxis (42) should be recommended
to any pregnant patient whose HIV screening test
result is reactive to reduce the risk for perinatal
Similarities and Differences Between
Current and Previous
Recommendations for Pregnant
Women and Their Infants
Aspects of these recommendations that remain unchanged
from previous recommendations are as follows:
• Universal HIV testing with notification should be
performed for all pregnant women as early as possible
• HIV screening should be repeated in the third trimester
of pregnancy for women known to be at high risk for
• Providers should explore and address reasons for
declining HIV testing.
• Pregnant women should receive appropriate health
education, including information regarding HIV and
its transmission, as a routine part of prenatal care.
• Access to clinical care, prevention counseling, and sup-
port services is essential for women with positive HIV
Aspects of these recommendations that differ from previ-
ous recommendations are as follows:
• HIV screening should be included in the routine panel of
prenatal screening tests for all pregnant women. Patients
should be informed that HIV screening is recommended
for all pregnant women and that it will be performed unless
they decline (opt-out screening).
• Repeat HIV testing in the third trimester is recommended
for all women in jurisdictions with elevated HIV or AIDS
incidence and for women receiving health care in facili-
ties with at least one diagnosed HIV case per 1,000
pregnant women per year.
• Rapid HIV testing should be performed for all women in
labor who do not have documentation of results from an
HIV test during pregnancy. Patients should be informed
that HIV testing is recommended for all pregnant women
and will be performed unless they decline (opt-out screen-
ing). Immediate initiation of appropriate antiretroviral
prophylaxis should be recommended on the basis of a
reactive rapid HIV test result, without awaiting the result
of confirmatory testing.
Additional Considerations for
• Communicating test results. The central goal of HIV
screening in health-care settings is to maximize the num-
ber of persons who are aware of their HIV infection and
receive care and prevention services. Definitive mecha-
nisms should be established to inform patients of their
test results. HIV-negative test results may be conveyed
without direct personal contact between the patient and
the health-care provider. Persons known to be at high risk
for HIV infection also should be advised of the need for
periodic retesting and should be offered prevention coun-
seling or referred for prevention counseling. HIV-
positive test results should be communicated
confidentially through personal contact by a clinician,
nurse, mid-level practitioner, counselor, or other skilled
staff. Because of the risk of stigma and discrimination,
family or friends should not be used as interpreters to
disclose HIV-positive test results to patients with lim-
ited English proficiency. Active efforts are essential to
ensure that HIV-infected patients receive their positive
Vol. 55 / RR-14 Recommendations and Reports11
test results and linkage to clinical care, counseling, sup-
port, and prevention services. If the necessary expertise
is not available in the health-care venue in which screen-
ing is performed, arrangements should be made to
obtain necessary services from another clinical provider,
local health department, or community-based organi-
zation. Health-care providers should be aware that the
Privacy Rule under the Health Insurance Portability
and Accountability Act of 1996 (HIPAA) prohibits use
or disclosure of a patient’s health information, includ-
ing HIV status, without the patient’s permission.
• Rapid HIV tests. Because of the time that elapses
before results of conventional HIV tests are available,
providing patients with their test results can be resource
intensive and challenging for screening programs,
especially in episodic care settings (e.g., EDs, urgent-
care clinics, and STD clinics) in which continuing
relationships with patients typically do not exist. The
use of rapid HIV tests can substantially decrease the
number of persons who fail to learn their test results
and reduce the resources expended to locate persons
identified as HIV infected. Positive rapid HIV test
results are preliminary and must be confirmed before
the diagnosis of HIV infection is established (111).
• Participants in HIV vaccine trials. Recipients of pre-
ventive HIV vaccines might have vaccine-induced
antibodies that are detectable by HIV antibody tests. Per-
sons whose test results are HIV positive and who are iden-
tified as vaccine trial participants might not be infected
with HIV and should be encouraged to contact or return
to their trial site or an associated trial site for the confir-
matory testing necessary to determine their HIV status.
• Documenting HIV test results. Positive or negative
HIV test results should be documented in the patient’s
confidential medical record and should be readily avail-
able to all health-care providers involved in the patient’s
clinical management. The HIV test result of a preg-
nant woman also should be documented in the medi-
cal record of her infant. If the mother’s HIV test result
is positive, maternal health-care providers should, after
obtaining consent from the mother, notify pediatric
care providers of the impending birth of an HIV-ex-
posed infant and of any anticipated complications. If
HIV is diagnosed in the infant first, health-care pro-
viders should discuss the implications for the mother’s
health and help her to obtain care.
Clinical Care for HIV-Infected Persons
Persons with a diagnosis of HIV infection need a thor-
ough evaluation of their clinical status and immune func-
tion to determine their need for antiretroviral treatment or
other therapy. HIV-infected persons should receive or be
referred for clinical care promptly, consistent with USPHS
guidelines for management of HIV-infected persons (96).
HIV-exposed infants should receive appropriate
antiretroviral prophylaxis to prevent perinatal HIV trans-
mission as soon as possible after birth (42) and begin
trimethoprim-sulfamethoxazole prophylaxis at age 4–6
weeks to prevent Pneumocystis pneumonia (112). They
should receive subsequent clinical monitoring and diag-
nostic testing to determine their HIV infection status
Partner Counseling and Referral
When HIV infection is diagnosed, health-care providers
should strongly encourage patients to disclose their HIV sta-
tus to their spouses, current sex partners, and previous sex
partners and recommend that these partners be tested for HIV
infection. Health departments can assist patients by notify-
ing, counseling, and providing HIV testing for partners with-
out disclosing the patient’s identity (114). Providers should
inform patients who receive a new diagnosis of HIV infection
that they might be contacted by health department staff for a
voluntary interview to discuss notification of their partners.
Special Considerations for Screening
Although parental involvement in an adolescent’s health care
is usually desirable, it typically is not required when the ado-
lescent consents to HIV testing. However, laws concerning
consent and confidentiality for HIV care differ among states
(79). Public health statutes and legal precedents allow for evalu-
ation and treatment of minors for STDs without parental
knowledge or consent, but not every state has defined HIV
infection explicitly as a condition for which testing or treat-
ment may proceed without parental consent. Health-care pro-
viders should endeavor to respect an adolescent’s request for
privacy (79). HIV screening should be discussed with all ado-
lescents and encouraged for those who are sexually active. Pro-
viding information regarding HIV infection, HIV testing, HIV
transmission, and implications of infection should be regarded
as an essential component of the anticipatory guidance
provided to all adolescents as part of primary care (79).
12 MMWR September 22, 2006
Prevention Services for HIV-Negative
• Risk screening. HIV screening should not be contin-
gent on an assessment of patients’ behavioral risks.
However, assessment of risk for infection with HIV and
other STDs and provision of prevention information
should be incorporated into routine primary care of all
sexually active persons when doing so does not pose a
barrier to HIV testing. Even when risk information is
not sought, notifying a patient that routine HIV test-
ing will be performed might result in acknowledgement
of risk behaviors and offers an opportunity to discuss
HIV infection and how it can be prevented. Patients
found to have risk behaviors (e.g., MSM or heterosexu-
als who have multiple sex partners, persons who have
received a recent diagnosis of an STD, persons who
exchange sex for money or drugs, or persons who
engage in substance abuse) and those who want assis-
tance with changing behaviors should be provided with
or referred to HIV risk-reduction services (e.g., drug
treatment, STD treatment, and prevention counseling).
• Prevention counseling. In health-care settings, preven-
tion counseling need not be linked explicitly to HIV test-
ing. However, because certain patients might be more
likely to think about HIV and consider their risks at the
time of HIV testing, testing might present an ideal
opportunity to provide or arrange for prevention coun-
seling to assist with behavior changes that can reduce
risks for acquiring HIV infection. Prevention counsel-
ing should be offered or made available through refer-
ral in all health-care facilities serving patients at high
risk for HIV and at facilities (e.g., STD clinics) in which
information on HIV risk behaviors is elicited routinely.
• Risk-factor ascertainment for HIV-infected persons.
CDC recommends that providers ascertain and document
all known HIV risk factors (115). Health-care providers
can obtain tools and materials to assist with ascertain-
ment and receive guidance on risk factors as defined for
surveillance purposes from HIV/AIDS surveillance pro-
fessionals in their state or local health jurisdiction. This
risk-factor information is important for guiding public
health decisions, especially for prevention and care, at
clinical, local, state, and national levels.
• HIV/AIDS case reporting. All states require that
health-care providers report AIDS cases and persons
with a diagnosis of HIV infection to the state or local
health department. Case report forms are available from
the state or local health jurisdiction.
• Pediatric exposure reporting. CDC and the Council
for State and Territorial Epidemiologists recommend
that all states and territories conduct surveillance for
perinatal HIV exposure and contact providers after
receiving reports of exposed infants to determine the
infant’s HIV-infection status. Information concerning
dates of maternal HIV tests, receipt of prenatal care,
maternal and neonatal receipt of antiretroviral drugs,
mode of delivery, and breastfeeding is collected on the
pediatric HIV/AIDS case report form (115).
Monitoring and Evaluation
Recommended thresholds for screening are based on
estimates of the prevalence of undiagnosed HIV infection
in U.S. health-care settings, for which no accurate recent
data exist. The optimal frequency for retesting is not yet
known. Cost-effectiveness parameters for HIV screening
were based on existing program models, all of which
include a substantial counseling component, and did not
consistently consider secondary infections averted as a ben-
efit of screening. To assess the need for revised thresholds
for screening adults and adolescents or repeat screening of
pregnant women and to confirm their continued effective-
ness, screening programs should monitor the yield of new
diagnoses of HIV infection, monitor costs, and evaluate
whether patients with a diagnosis of HIV infection are linked
to and remain engaged in care. With minor modifications,
laboratory information systems might provide a practical
alternative for clinicians to use in determining HIV preva-
lence among their patients who are screened for HIV.
Primary Prevention and HIV Testing
in Nonclinical Settings
These revised recommendations are designed to increase
HIV screening in health-care settings. Often, however, the
population most at risk for HIV includes persons who are
least likely to interact with the conventional health-care sys-
tem (47,116). The need to maintain primary prevention
activities, identify persons at high risk for HIV who could
benefit from prevention services, and provide HIV testing for
persons who are at high risk for HIV in nonclinical venues
remains undiminished. New approaches (e.g., enlisting
Vol. 55 / RR-14Recommendations and Reports13
BOX 2. Other guidelines and recommendations
• CDC. Updated U.S. Public Health Service guidelines
for the management of occupational exposures to HIV
and recommendations for postexposure prophylaxis.
MMWR 2005;54(No. RR-9):1–17.
• CDC. Antiretroviral postexposure prophylaxis after
sexual, injection-drug use, or other nonoccupational
exposure to HIV in the United States: recommenda-
tions from the U.S. Department of Health and Human
Services. MMWR 2005;54(No. RR-2):1–20.
• CDC. Incorporating HIV prevention into the medical
care of persons living with HIV: recommendations of
CDC, the Health Resources and Services Administra-
tion, the National Institutes of Health, and the HIV
Medicine Association of the Infectious Diseases Society
of America. MMWR 2003;52(No. RR-12):1–24.
• US Department of Health and Human Services,
Office for Civil Rights. National standards to protect
the privacy of personal health information. Available at
• US Department of Health and Human Services,
Office for Civil Rights. Guidance to federal financial
assistance recipients regarding Title VI prohibition
against national origin discrimination affecting limited
English proficient persons. Available at http://
HIV-infected persons and HIV-negative persons at high risk
for HIV to recruit persons from their social, sexual, and
drug-use networks for counseling, testing, and referral) have
demonstrated considerable efficacy for identifying persons
who were previously unaware of their HIV infection (117).
Regulatory and Legal Considerations
These public health recommendations are based on best
practices and are intended to comply fully with the ethical
principles of informed consent (67). Legislation related to
HIV and AIDS has been enacted in every state and the
District of Columbia (118), and specific requirements
related to informed consent and pretest counseling differ
among states (119). Certain states, local jurisdictions, or
agencies might have statutory or other regulatory impedi-
ments to opt-out screening, or they might impose other
specific requirements for counseling, written consent, con-
firmatory testing, or communicating HIV test results that
conflict with these recommendations. Where such policies
exist, jurisdictions should consider strategies to best imple-
ment these recommendations within current parameters
and consider steps to resolve conflicts with these recom-
Issues that fall outside the scope of these recommenda-
tions are addressed by other USPHS guidelines (Box 1).
Because concepts relevant to HIV management evolve rap-
idly, USPHS updates recommendations periodically. Cur-
rent updates are available from the National Institutes of
Health at http://AIDSinfo.nih.gov. Additional guidelines
have been published by CDC and the U.S. Department of
Health and Human Services, Office for Civil Rights (Box 2).
Ida M. Onorato, MD, Division of HIV/AIDS Prevention, National
Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
(proposed), contributed to the writing and revision of this report.
1. CDC. Cases of HIV infection and AIDS in the United States, 2004.
HIV/AIDS Surveillance Report 2005;16:16–45.
2. Lindegren ML, Byers RH, Thomas P, et al. Trends in perinatal trans-
mission of HIV/AIDS in the United States. JAMA 1999;282:531–8.
3. CDC. Number of persons tested for HIV—United States, 2002.
4. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at
the end of 2003 [Abstract]. Presented at the National HIV Prevention
Conference, June 12–15, 2005; Atlanta, Georgia.
5. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-
risk sexual behavior in persons aware and unaware they are infected
with HIV in the United States: implications for HIV prevention
programs. J Acquir Immune Defic Syndr 2005;39:446–53.
6. Palella FJ, Deloria-Knoll M, Chmiel JS, et al. Survival benefit of initi-
ating antiretroviral therapy in HIV-infected persons in different CD4+
cell strata. Ann Intern Med 2003;138:620–6.
7. Wortley PM, Chu SY, Diaz T, et al. HIV testing patterns: where, why,
and when were persons with AIDS tested for HIV? AIDS 1995;9:
BOX 1. Recent U.S. Public Health Service HIV treatment
• Guidelines for the use of antiretroviral agents in HIV-
infected adults and adolescents
• Guidelines for the use of antiretroviral agents in pediat-
ric HIV infection
• Recommendations for use of antiretroviral drugs in
pregnant HIV-1-infected women for maternal health
and interventions to reduce perinatal HIV-1 trans-
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Vol. 55 / RR-14 Recommendations and Reports17
Membership List, November 2005
Chairpersons: Bernard M. Branson, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC; H. Hunter
Handsfield, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed) and University of Washington, Seattle, Washington.
Presenters: Terje Anderson, National Association of People with AIDS, Silver Spring, Maryland; Yvette Calderon, MD, Albert Einstein College of Medicine,
Bronx, New York; Carlos del Rio, Emory University School of Medicine, Atlanta, Georgia; Bambi Gaddist, PhD, South Carolina African American HIV/
AIDS Council, Columbia, South Carolina; Roberta Glaros, MA, New York State Department of Health, Albany, New York; Howard A. Grossman, MD,
American Academy of HIV Medicine, Washington, DC; Sara Guerry, MD, Los Angeles Sexually Transmitted Disease Program, Los Angeles, California; Scott
D. Halpern, MD, PhD, University of Pennsylvania, Philadelphia, Pennsylvania; Kim Hamlett-Berry, PhD, Department of Veterans Affairs, Washington, DC;
Scott Kellerman, MD, New York City Bureau of HIV/AIDS Prevention and Control, New York, New York; James H. Lee, Texas Department of State Health
Services, Austin, Texas; Jason Leider, MD, PhD, Albert Einstein College of Medicine, Bronx, New York; A. David Paltiel, PhD, Yale University School of
Medicine, New Haven, Connecticut; Liisa Randall, PhD, Michigan Department of Community Health, Okemos, Michigan; Cornelis A. Rietmeijer, MD,
PhD, Denver Public Health Department, Denver, Colorado; Robert A. Weinstein, MD, Rush Medical College, Chicago, Illinois; Noel Zuniga, Bienestar
Human Services, Inc., Los Angeles, California.
Moderators: John Blevins, Emory University School of Medicine, Atlanta, Georgia; William C. Page, William C. Page, Inc., Albuquerque, New Mexico.
Consultants: Chris Aldridge, National Alliance of State and Territorial AIDS Directors, Washington, DC; Terje Anderson, National Association of People
with AIDS, Silver Spring, Maryland; Arlene Bardeguez, MD, University of Medicine and Dentistry of New Jersey, Newark, New Jersey; Ronald Bayer, PhD,
Mailman School of Public Health, Columbia University, New York, New York; Guthrie Birkhead, MD, Council of State and Territorial Epidemiologists and
New York State Department of Health, Albany, New York; Lora Branch, MS, Chicago Department of Public Health, Chicago, Illinois; Daniel Bush, North
Jersey Community Research Initiative, Newark, New Jersey; Ahmed Calvo, MD, Health Resources and Services Administration, Rockville, Maryland; Sheldon
Campbell, MD, PhD, College of American Pathologists and Yale University School of Medicine, New Haven, Connecticut; Suzanne Carlberg-Racich, MPH,
Midwest AIDS Training and Education Center, Chicago, Illinois; Sandra Chamblee, Glades Health Initiative, Belle Glade, Florida; James Coleman, Whitman
Walker Clinic, Inc., Takoma Park, Maryland; Kevin DeCock, MD, Global AIDS Program, Nairobi, Kenya; Andrew De Los Reyes, Gay Men’s Health Crisis,
Inc., New York, New York; Carlos del Rio, Emory University School of Medicine, Atlanta, Georgia; Marisa Duarte, MPH, Centers for Medicare and Medicaid
Services, Atlanta, Georgia; Wayne Duffus, MD, PhD, South Carolina Department of Health and Environmental Control, Columbia, South Carolina; Enid
Eck, Kaiser Permanente, Pasadena, California; Magdalena Esquivel, Los Angeles Department of Health Services, Los Angeles, California; Joe Fuentes, Houston
Area Community Services, Inc., Houston, Texas; Donna Futterman, MD, American Academy of Pediatrics and Albert Einstein College of Medicine, Bronx,
New York; Bambi Gaddist, PhD, South Carolina African American HIV/AIDS Council, Columbia, South Carolina; Roberta Glaros, MA, New York State
Department of Health, Albany, New York; Howard A. Grossman, MD, American Academy of HIV Medicine, Washington, DC; Sara Guerry, MD, Los
Angeles Sexually Transmitted Disease Program, Los Angeles, California; Scott D. Halpern, MD, PhD, University of Pennsylvania, Philadelphia, Pennsylvania;
Kim Hamlett-Berry, PhD, Department of Veterans Affairs, Washington, DC; Celine Hanson, MD, Baylor College of Medicine, Houston, Texas; Wilbert
Jordan, MD, National Medical Association and Drew University, Los Angeles, California; Scott Kellerman, MD, New York City Bureau of HIV/AIDS
Prevention and Control, New York, New York; David Lanier, MD, Agency for Healthcare Research and Quality, Rockville, Maryland; James H. Lee, Texas
Department of State Health Services, Austin, Texas; Jason Leider, MD, PhD, Albert Einstein College of Medicine, Bronx, New York; Elisa Luna, MSW,
Washington, DC; Robert Maupin, MD, American College of Obstetricians and Gynecologists and LSU Health Sciences Center, New Orleans, Louisiana;
Jenny McFarlane, Texas Department of State Health Services, Austin, Texas; Lynne Mofenson, MD, National Institute of Child Health and Human Development,
Rockville, Maryland; Eve Mokotoff, MPH, Council of State and Territorial Epidemiologists and Michigan Department of Community Health, Detroit,
Michigan; Susan Moskosky, MS, Office of Population Affairs, Rockville, Maryland; Doralba Muñoz, Union Positiva, Inc., Miami, Florida; George Odongi,
Dorchester Community Health Center, Quincy, Massachusetts; Debra Olesen, JSI Research and Training, Denver, Colorado; A. David Paltiel, PhD, Yale
School of Medicine, New Haven, Connecticut; Paul Palumbo, MD, Newark, New Jersey; Jim Pickett, AIDS Foundation of Chicago, Chicago, Illinois; Pam
Pitts, MPH, Tennessee Department of Health, Nashville, Tennessee; Borris Powell, Gay Men of African Descent, New York, New York; Liisa Randall, PhD,
Michigan Department of Community Health, Okemos, Michigan; Mobeen Rathore, MD, University of Florida, Jacksonville, Florida; Cornelis A. Rietmeijer,
MD, PhD, Denver Public Health Department, Denver, Colorado; Sam Rivera, Fortune Society, New York, New York; Ruth Roman, MPH, Health Resources
and Services Administration, Rockville, Maryland; Richard Rothman, MD, Johns Hopkins University and American College of Emergency Physicians,
Baltimore, Maryland; Gale Sampson-Lee, National Black Leadership Commission on AIDS, New York, New York; John Schneider, MD, PhD, American
Medical Association, Flossmoor, Illinois; Deya Smith-Starks, AIDS Healthcare Foundation, Los Angeles, California; Nilda Soto, PROCEED, Inc., Elizabeth,
New Jersey; Alice Stek, MD, University of Southern California School of Medicine, Los Angeles, California; Monica Sweeney, MD, Bedford Stuyvesant
Family Health Center, Inc., and National Association of Community Health Centers, Brooklyn, New York; Donna Sweet, MD, Wichita, Kansas; Wanda
Tabora, Iniciativa Communitaria de Investigacion, San Juan, Puerto Rico; Mark Thrun, MD, Denver Public Health, Denver, Colorado; Robert A. Weinstein,
MD, Rush Medical College, Chicago, Illinois; Carmen Zorilla, MD, University of Puerto Rico School of Medicine, San Juan, Puerto Rico; Noel Zuniga,
Bienestar Human Services, Inc., Los Angeles, California.
Peer Reviewers: Connie Celum, MD, University of Washington, Seattle, Washington; Daniel Kuritzkes, MD, HIV Medicine Association and Brigham and
Women’s Hospital, Cambridge, Massachusetts; Thomas C. Quinn, MD, National Institute of Allergy and Infectious Disease and Johns Hopkins University,
CDC, Division of HIV/AIDS Prevention Revised Recommendations for HIV Testing
in Health-Care Settings Project
Coordinator: Bernard M. Branson, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC.
Project Manager: Samuel A. Martinez, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC.
CDC Presenters: Brian Boyett, MS, Bernard M. Branson, MD, H. Irene Hall, PhD, Margaret A. Lampe, MPH, Sheryl B. Lyss, MD, Duncan A. Mackellar,
MPH, Stephanie L. Sansom, PhD, Allan W. Taylor, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed).
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