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Screening for HIV Infection in Asymptomatic, Nonpregnant Adolescents and Adults: A Systematic Review for the U.S. Preventive Services Task Force
Evidence Synthesis, No. 176
Investigators: Roger Chou, MD, Tracy Dana, MLS, Sara Grusing, BA, and Christina Bougatsos, MPH.
Structured Abstract
Background:
A 2012 systematic review on HIV screening for the U.S. Preventive Services Task Force (USPSTF) found strong evidence that antiretroviral therapy (ART) is associated with improved clinical outcomes in persons with CD4+ T helper cell (CD4) counts less than 500 cells/mm3 and substantially decreases risk of HIV transmission, with certain antiretroviral agents potentially associated with long-term cardiovascular harms. The USPSTF previously found HIV screening tests to be highly accurate.
Purpose:
To systematically update the 2012 USPSTF review on screening for HIV in adolescents and adults, focusing on research gaps identified in the prior review.
Data Sources:
We searched the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and MEDLINE (2012 to June 2018) and manually reviewed reference lists, with surveillance through January 2019.
Study Selection:
Randomized, controlled trials (RCTs) and controlled observational studies on benefits and harms of screening versus no screening and on the yield of screening at different intervals; the effects of earlier versus later initiation of ART; and long-term (≥2 years) harms of ART.
Data Extraction:
One investigator abstracted data and a second investigator checked data abstraction for accuracy. Two investigators independently assessed study quality using methods developed by the USPSTF.
Data Synthesis (Results):
We did not identify any studies on benefits or harms of HIV screening versus no screening, or on the yield of repeat versus one-time screening or of screening at different intervals. Two new RCTs conducted completely or partially in low-resource settings found initiation of ART in persons with CD4 counts greater than 500 cells/mm3 associated with lower risk of composite clinical outcomes (mortality, AIDS-defining events, or serious non-AIDS events) (relative risk [RR], 0.44 [95% confidence interval (CI), 0.31 to 0.63] and RR, 0.57 [95% CI, 0.35 to 0.95]); early initiation of ART was not associated with increased risk of cardiovascular events. A large observational study also found initiation of ART in persons in high-resource settings with CD4 counts greater than 500 cells/mm3 to be associated with reduced risk of mortality or AIDS events, although the magnitude of effect was smaller. New evidence regarding the association between abacavir use and increased risk of cardiovascular events was inconsistent, and certain antiretroviral regimens were associated with increased risk of long-term neuropsychiatric, renal, hepatic, and bone adverse events.
Limitations:
Only English-language articles were included. Observational studies were included. Studies conducted in resource-poor settings were included, which might limit applicability to general screening in the United States.
Conclusions:
New evidence extends effectiveness of ART to asymptomatic persons with CD4 counts greater than 500 cells/mm3. Certain ART regimens may be associated with long-term cardiovascular, neuropsychiatric, hepatic, renal, or bone harms, but early initiation of ART is not associated with increased risk of cardiovascular events. Research is needed to inform optimal screening intervals.
Contents
- Acknowledgments
- Chapter 1. Introduction and Background
- Chapter 2. Methods
- Chapter 3. Results
- Key Question 1. What Are the Benefits of Screening for HIV Infection in Asymptomatic, Nonpregnant Adolescents and Adults on Mortality, AIDS and Opportunistic Infections, Quality of Life, Function, and Reduced Transmission of HIV and Other STIs?
- Key Question 2. What Is the Yield of Screening for HIV Infection at Different Intervals in Asymptomatic, Nonpregnant Adolescents and Adults, and How Does the Screening Yield Vary in Different Risk Groups?
- Key Question 3. What Are the Harms of Screening for HIV Infection in Asymptomatic, Nonpregnant Adolescents and Adults?
- Key Question 4. What Are the Effects of Initiating ART in Adolescents and Adults With Chronic HIV Infection at a Higher Versus Lower CD4 Count on Mortality, AIDS and Opportunistic Infections, Quality of Life, Function, and Reduced Transmission of HIV and Other STIs?
- Key Question 5. What Are the Longer-Term Harms (2 Years or More) Associated With Currently Recommended ART Regimens?
- Chapter 4. Discussion
- References
- Appendixes
Suggested citation:
Chou R, Dana T, Grusing S, Bougatsos C. Screening for HIV Infection in Asymptomatic, Nonpregnant Adolescents and Adults: A Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 176. AHRQ Publication No. 18-05246-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2019.
This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA-290-2015-00009-I, Task Order No. 7). The findings and conclusions in this document are those of the authors, who are responsible for its contents, and do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information (i.e., in the context of available resources and circumstances presented by individual patients).
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
None of the investigators have any affiliations or financial involvement that conflict with the material presented in this report.
- NLM CatalogRelated NLM Catalog Entries
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