Although HIV transmission rates have decreased in recent years, the virus is still passed on at alarming rates. In the United States, 40,000 people are infected annually. More than 1 million Americans are living with the disease today, and of those, 25 percent are unaware of their HIV-positive status. It's estimated that 54 percent of new HIV infections are caused by people unaware of their HIV-positive status. Many people who present in the later stages of their HIV infection have had earlier contact with a healthcare provider. That prior contact constitutes a missed opportunity to diagnose, connect to care and provide counseling to prevent further HIV transmission.

New Recommendations for HIV Testing
On Sept. 22, 2006, the Centers for Disease Control and Prevention issued a variety of recommendations about HIV testing. CDC officials contend that HIV tests should be a routine component of health maintenance activities--just like pap smears, immunizations and colon cancer screening. Here are the CDC recommendations:

* All patients 13-64, regardless of risk, should be tested at least once.

* An "opt-out" approach should be implemented by notifying patients that HIV testing will be performed unless they decline.

* General consent for medical procedures is adequate for all care, including HIV testing. A separate consent form is not necessary.

* Annual repeat screening is recommended for a subpopulation of individuals including:
1. Intravenous drug users and their intimate partners.
2. People exchanging sex for money or drugs.
3. Partners of people infected with HIV.
4. Men who have sex with men.
5. Heterosexuals who themselves or whose partners have had more than one partner since their last HIV test.

* HIV testing should be included in routine prenatal laboratory panels.

* Repeat HIV testing should be provided in the third trimester of pregnancy for women at high risk for HIV.

For more information about the CDC's  HIV testing guidelines, visit www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.

Physicians' Role in HIV Testing Procedures
While routine opt-out testing is not yet possible in California due to state HIV testing laws, there are ways to streamline HIV testing procedures to more closely align them with the new recommendations. California law requires physicians to obtain consent for testing, but that consent need not be written except when testing pregnant women. Thus, physicians in most instances can choose to obtain verbal consent. However, physician assistants and nurse practitioners cannot obtain verbal informed consent in California and must continue to obtain written consent when testing for HIV.

Additionally, while post-test counseling is critical for ensuring access to care and reduction in risk behavior associated with HIV transmission, physicians are not required to perform pre-test counseling.

Rapid HIV Testing
Rapid HIV testing has the ability to further reduce barriers to patients learning their HIV status by providing test results within 20-40 minutes. If the HIV test is negative, no additional testing is needed. If the HIV test is positive, preliminary results are given and a sample of blood or fluid is obtained for confirmatory testing. Results are confirmed in 4-7 days. Rapid testing has proven to be very successful and is associated with increased disclosure of HIV test results and high patient satisfaction.

Below is a step-by-step process for implementing a rapid HIV testing program:

1. Choose a rapid test. The FDA has approved six rapid HIV tests (see the Web site listed below for details).

2. Apply for a Clinical Laboratory Improvement Amendment certificate. Agencies must obtain a CLIA certificate of waiver or higher.

3. Receive approval to perform HIV antibody testing. Facilities must have a California clinical or public health laboratory license and enroll in a California Department of Health Services-approved proficiency-testing program for HIV testing.

4. Ensure appropriate personnel qualifications. Personnel conducting the test must be qualified to conduct CLIA-waived tests under Business and Professions Code Section 1206.5. Personnel such as physicians, physician assistants, nurses and medical assistants providing direct patient care can qualify.

For more information on rapid HIV testing, visit the CDC's Web site at www.cdc.gov/hiv/topics/testing/rapid/index.htm.

All the authors work in the Office of AIDS Programs and Policy at the Los Angeles County Department of Public Health. Mary Orticke, RN, MPH, is director of clinical services. Sophia Rumanes, MPH, is director of prevention services. Jan King, MD, MPH, is medical director.