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Guidelines for HIV/AIDS Diagnosis and Treatment

Christina Mattina
These guidelines provide an overview of the current recommendations surrounding HIV/AIDS diagnosis, treatment, and complications.
More than 35 years after the medical community first recognized acquired immunodeficiency syndrome (AIDS), the disease, and the human immunodeficiency virus (HIV), that causes it remain a serious global health challenge. HIV attacks the body’s immune system by destroying T cells and leaving the person susceptible to opportunistic infections or infection-related cancers, which signal that the patient has AIDS, the last stage of HIV infection.1 The most common mode of infection is through sexual contact, followed by blood-borne and mother-to-child transmission.2 Worldwide, 36.7 million people currently live with HIV/AIDS, but as of June 2016, only 18.2 million of those were regularly accessing antiretroviral therapy, the primary treatment for the still-incurable disease.3

These guidelines provide an overview of the current recommendations surrounding HIV/AIDS diagnosis, treatment, and complications.

Testing Recommendations
HIV testing and counseling is an essential first step in controlling the virus, but the World Health Organization (WHO) reports that only about half of people currently infected with HIV worldwide are aware of their status.4 This proportion is even lower among people in key at-risk populations, including men who have sex with men, people who inject drugs, people in prisons, sex workers, and transgender people. People in these groups tend to test late or have insufficient links from testing to care, meaning that their immune systems are already compromised when treatment is initiated.

The WHO guidelines emphasize some important components of successful HIV testing.4 First, counseling must be provided both before and after testing to provide accurate information about the potential test results, allowing the person to make informed choices. Even for people who test negative, counselors can offer helpful advice on safer sex and risk reduction.

Thanks to the advances in rapid HIV testing, screening can and should occur across multiple settings, including within community outreach efforts, healthcare provider offices, and clinics. Another development that could increase access is the availability of self-testing, which can be performed at home and requires physician follow-up in the event of a positive result. The test can be done at home in less than 20 minutes using either oral fluid or blood from a finger prick. In a statement announcing newly issued guidelines on self-testing, WHO Director Dr Margaret Chan said that self-testing “should open the door for many more people to know their HIV status and find out how to get treatment and access prevention services.”5

Self-testing could potentially be a key tool in helping to ensure confidentiality, one of the WHO’s essential "5 Cs" of HIV testing. The others are consent, counseling, correct test results, and connections to treatment. Counseling and confidentiality are especially important for adolescents, who should be able to obtain testing without parental knowledge and should be supported in their decision on whether to disclose positive HIV status.4

Laboratory Testing
The CDC guidelines on laboratory testing for the diagnosis of HIV were updated in 2014 after years of literature review. To summarize the new algorithm, testing of serum or plasma should begin “with a combination immunoassay that detects HIV-1 and HIV-1 antibodies and HIV-1 p24 antigen. All specimens reactive on this initial assay undergo supplemental testing with an immunoassay that differentiates HIV-1 from HIV-2 antibodies. Specimens that are reactive on the initial immunoassay and nonreactive or indeterminate on the antibody differentiation assay proceed to HIV-1 nucleic acid testing for resolution.”6

If a positive test result occurs after this recommended algorithm, the patient will then undergo further testing, including HIV-1 viral load, CD4+ T-lymphocyte determination, and an antiretroviral resistance assay, to determine the stage of the disease and help select an appropriate treatment regimen.

This represents a change from the previous guidelines, which recommended using the HIV-1 Western blot and HIV-1 indirect immunofluorescence assay (IFA). In the interim before the release of the updated guidelines, the FDA had approved various improved immunoassay tests, including one that can differentiate HIV-1 from HIV-2 antibodies. The updates are based on these advances, as well as on evidence that Western blot and IFA tests “can produce false-negative or indeterminate results early in the course of HIV infection,” and that the Western blot often misclassifies HIV-2 infections as HIV-1.6

Aside from the improved accuracy, the new testing algorithm can also help shorten the interval between specimen collection and test result notification by 1 week, according to a testing program cited in the guidelines. Another laboratory found that 96% of antibody-positive results could be reported in 2 workdays or less when using the new algorithm, compared with 22% for the specimens tested with the previous algorithm.6

The guidelines also included recommendations for reporting test results to both the person who ordered the test and public health authorities. They advise that reports to the person who ordered the test should specify all assays used and their results, how to interpret the results, and any additional tests that may be required. All results should be reported to the person when testing is complete, but laboratories should only report results indicative of HIV infection to the appropriate public health authorities. Tests indicating the presence of acute HIV infection call for expedited reporting to both the infected person and to public health authorities.6

Copyright AJMC 2006-2018 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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