Making the Case

Why test for HIV in the emergency department?

HIV disproportionately affects populations that are likely to be without a regular source of care or have a history of barriers to care, which may contribute to delayed diagnosis and further transmission of HIV.(13) Many are dependent on the public sector for the financing and delivery of their care. It is estimated that 45 percent of HIV-infected persons have no health insurance; 30 percent receive coverage through Medicaid; and 2 percent have Medicare.(14) Consequently, EDs—whose patients include large numbers of underinsured and uninsured—are likely the only source of health care for many people with HIV or at risk for HIV.(15-19) High rates of newly diagnosed HIV infection among ED patients who are uninsured or with Medicaid support the argument that many ED patients with HIV do not seek or have ready access to other health care sources.(20)

The HIV disease burden in some EDs, particularly urban EDs, surpasses the threshold to warrant screening.(21) Rothman's review of HIV sero-prevalence studies found rates of 2 to 17 percent in EDs across the country, with unrecognized disease rates of 1 to 5 percent.(20, 22-27)

The rest of this section summarizes current research on the following:

• The clinical benefit of expanded HIV testing
• The public health benefit of expanded HIV testing
• The scope of HIV testing in EDs nationwide
• The feasibility and cost-effectiveness of ED-based HIV testing
• Current recommendations for HIV testing for health care providers

Cited Sources

13.  Levi J, Kates J. HIV: challenging the health care delivery system. Am J Public Health. July 2000;90(7):1033-1036.
14.  Centers for Disease Control and Prevention. Questions and Answers for Professional Partners: Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Healthcare Settings. Accessed May 3, 2007.
15.  Kaiser Family Foundation. Financing HIV/AIDS Care: A Quilt with Many Holes May 2004.
16.  Medical Access Study Group. Nowhere to go: Medicaid patient access to primary care. New Eng J Med. 1994;330:1426-1430.
17.  Sox C, Swartz K, Burstin H, Brennan T. Insurance or regular physician: Which is the most powerful predictor of health care. American Journal of Public Health. 1999;88(3):364-370.
18.  Sue D, Shahan J, Kelen G. Primary care access for Medicaid versus privately insured patients. Acad Emerg Med. 1994;1:A1.
19.  Zuvekas S, Weinick R. Changes in access to care, 1977-1996: The role of health insurance. Health Services Research. 1999;34(1):271.
20.  Kelen GD, Shahan JB, Quinn TC. Emergency department-based HIV screening and counseling: experience with rapid and standard serologic testing. Annals of Emergency Medicine. Feb 1999;33(2):147-155.
21.  Rothman RE, Ketlogetswe KS, Dolan T, Wyer PC, Kelen GD. Preventive care in the emergency department: should emergency departments conduct routine HIV screening? a systematic review. Academic Emergency Medicine. Mar 2003;10(3):278-285.
22.  Schoenbaum E, Webber MP. The underrecognition of HIV infection in women in an inner-city emergency room. American Journal of Public Health. 1993;83:363-368.
23.  Lindsay M, Grant J, Peterson H, Risby J, et al. Human immunodeficiency virus infection among patients in a gynecology emergency department. Obstetrics & Gynecology. 1993;81:1012-1015.
24.  Kelen GD, Hexter DA, Hansen KN, Tang N, Pretorius S, Quinn TC. Trends in human immunodeficiency virus (HIV) infection among a patient population of an inner-city emergency department: implications for emergency department-based screening programs for HIV infection. Clinical Infectious Diseases. Oct 1995;21(4):867-875.
25.  Kelen GD, Hexter DA, Hansen KN, et al. Feasibility of an emergency department-based, risk-targeted voluntary HIV screening program. Annals of Emergency Medicine. Jun 1996;27(6):687-692.
26.  Alpert PL, Shuter J, DeShaw MG, Webber MP, Klein RS. Factors associated with unrecognized HIV-1 infection in an inner-city emergency department. Annals of Emergency Medicine. Aug 1996;28(2):159-164.
27.  Goggin MA, Davidson AJ, Cantril SV, O'Keefe LK, Douglas JM. The extent of undiagnosed HIV infection among emergency department patients: results of a blinded seroprevalence survey and a pilot HIV testing program. Journal of Emergency Medicine. Jul 2000;19(1):13-19.

Clinical Benefit

In addition to promoting good public health, routine HIV testing can improve clinical care in the ED, especially for patients who present with conditions related to early, undetected HIV infection.

Earlier diagnosis of HIV through expanded testing efforts expedites access to appropriate treatment, thus improving the quality of care for infected patients. The remarkable developments in HIV treatment over the past ten years, specifically the introduction of highly active anti-retroviral therapy (HAART), dramatically reduce HIV-related morbidity and mortality.(11) Therefore, early identification and initiation of therapy, especially during the asymptomatic period, may delay disease progression and limit opportunistic infections, thus lengthening and improving the lives of those with HIV.

Click here for a clinical discussion of the value of HIV testing.

Cited Sources

11. Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States - an analysis of cost-effectiveness. New England Journal of Medicine. Feb 10 2005;352(6):586-595.

Public Health Benefit

Approximately one-quarter of the 925,000 to 1,025,000 people infected with HIV are unaware of their infection.(2) Many learn of their HIV-positive serostatus only after it has progressed to AIDS.(3) Some estimate that those unaware of their HIV infection are 3.5 times more likely to transmit the virus to others.(4-6) In addition to preserving the health of those infected,(6, 7) early diagnosis of HIV infection can limit further transmission when those who are infected alter their risk behavior(8) and maintain sufficiently low viral loads.(9)

Analysts project that widespread use of HIV screening would be cost-effective(10-12) in all but the populations with lowest risk (<.02% HIV prevalence).(10, 11)

Cited Sources

2. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. National HIV Prevention Conference. Atlanta, GA; 2005.
3. Centers for Disease Control and Prevention. HIV/AIDS surveillance report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2005.
4. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. Sept 22, 2006;55(RR-14):1-17.
5. Marks G, Crepaz N, Janssen R. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. June 26 2006;20(10):1447-1450.
6. Marks G, Crepaz N, Senterfitt J, Janssen R. 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;39:446-453.
7. Palella F, Deloria-Knoll M, Chmiel J, et al. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Ann Intern Med 2003;138:620-626.
8. Colfax GN, Buchbinder SP, Cornelisse PGA, Vittinghoff E, Mayer K, Celum C. Sexual risk behaviors and implications for secondary HIV transmission during and after HIV seroconversion. AIDS. Jul 26 2002;16(11):1529-1535.
9. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. New England Journal of Medicine. Mar 30 2000;342(13):921-929.
10. Paltiel AD, Walensky RP, Schackman BR, et al. Expanded HIV screening in the United States: Effect on clinical outcomes, HIV transmission and costs. Annals of Internal Medicine. 2006;145:797-806.
11. Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States - an analysis of cost-effectiveness. New England Journal of Medicine. Feb 10 2005;352(6):586-595.

The Scope of Nationwide HIV Testing in EDs

According to a 2004 hospital survey, 57 percent of hospitals provide HIV tests in their emergency departments.(28) To date, routine testing for HIV in EDs has been close to nonexistent,(28, 29) even for patients with sexually transmitted diseases.(28, 30) Most hospitals provide HIV testing in cases of occupational exposure or at the provider's discretion based on clinical presentation or other risk factors.(28)

While levels of HIV testing in EDs are low, there is reason to believe that the number of EDs that provide HIV testing will grow significantly over the next few years. For example, a small number of EDs have piloted HIV testing and have published their findings.(20, 24, 25, 27, 31-38) Some health departments, including those in Massachusetts,(38) Ohio,(35) New Jersey,(39) and Michigan(40) are collaborating with EDs and urgent care settings to offer HIV testing. The Society of Academic Emergency Medicine's 2007 annual meeting has a number of presentations focused on ED-based HIV testing.(41)

Cites Sources

20. Kelen GD, Shahan JB, Quinn TC. Emergency department-based HIV screening and counseling: experience with rapid and standard serologic testing. Annals of Emergency Medicine. Feb 1999;33(2):147-155.
24. Kelen GD, Hexter DA, Hansen KN, Tang N, Pretorius S, Quinn TC. Trends in human immunodeficiency virus (HIV) infection among a patient population of an inner-city emergency department: implications for emergency department-based screening programs for HIV infection. Clinical Infectious Diseases. Oct 1995;21(4):867-875.
25. Kelen GD, Hexter DA, Hansen KN, et al. Feasibility of an emergency department-based, risk-targeted voluntary HIV screening program. Annals of Emergency Medicine. Jun 1996;27(6):687-692.
27. Goggin MA, Davidson AJ, Cantril SV, O'Keefe LK, Douglas JM. The extent of undiagnosed HIV infection among emergency department patients: results of a blinded seroprevalence survey and a pilot HIV testing program. Journal of Emergency Medicine. Jul 2000;19(1):13-19.
28. Williams Torres G, Hasnain-Wynia R, Whitmore H, Pickreign J, Stanger JK. Hospital HIV Testing Policies and Practices: A National Survey: Health Research and Educational Trust; 2005.
29. Wilson SR, Mitchell C, Bradbury DR, Chavez J. Testing for HIV: current practices in the academic ED. American Journal of Emergency Medicine. Jul 1999;17(4):354-356.
30. Fincher-Mergi M, Cartone KJ, Mischler J, Pasieka P, Lerner EB, Billittier A. Assessment of emergency department health care professionals' behaviors regarding HIV testing and referral for patients with STDs. AIDS Patient Care & Stds. Nov 2002;16(11):549-553.
31. Centers for Disease Control and Prevention. Routinely recommended HIV testing at an urban urgent-care clinic - Atlanta, Georgia, 2000. Morbidity and Mortality Weekly Report. 2001;50(25):538.
32. Coil CJ, Haukoos JS, Witt MD, Wallace RC, Lewis RJ. Evaluation of an emergency department referral system for outpatient HIV testing. Journal of Acquired Immune Deficiency Syndromes: JAIDS. Jan 1 2004;35(1):52-55.
33. Glick NR, Silva A, Zun L, Whitman S. HIV testing in a resource-poor urban emergency department. AIDS Education and Prevention. 2004;16(2):126.
34. Haukoos JS, Witt MD, Zeumer CM, Lee TJ, Halamka JD, Lewis RJ. Emergency department triage of patients infected with HIV. Academic Emergency Medicine. 2002;9(9):880.
35. Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Health department collaboration with emergency departments as a model for public health programs among at-risk populations. Public Health Reports. May-June 2005;120:259-265.
36. Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Emergency department HIV testing and counseling: an ongoing experience in a low-prevalence area. Annals of Emergency Medicine. Jul 2005;46(1):22-28.
37. Lyss SB, Branson BM, Kroc KA, Couture EF, Newman DR, Weinstein RA. Detecting unsuspected HIV infection with a rapid whole-blood HIV test in an urban emergency department. J Acquir Immune Defic Syndr. 2007;44(4):435-442.
38. Walensky RP, Losina E, Malatesta L, et al. Effective HIV case identification through routine HIV screening at urgent care centers in Massachusetts. American Journal of Public Health. Jan 2005;95(1):71-73.
39. Paul SM, Cadoff E, Martin E, et al. Rapid HIV Testing in Emergency Departments: A Successful New Jersey Initiative. Prevention Health Week. New Brunswick; 2005.
40. Randall L. Personal communication. Michigan Department of Community Health; 2006: Key informant interview.
41. 2007 Society for Academic Emergency Medicine Annual Meeting Abstracts. Academic Emergency Medicine. 2007;14(5, Supplement 1).

Cost-Effectiveness and Feasibility

Early studies have found that HIV testing is feasible in busy, urban EDs.(20, 25, 33, 36, 38) The table below highlights findings from these studies.

Some sites have demonstrated that even with modest resources (e.g., $75,000(33) to $141,975(20) for risk-based testing and $232,000(38) for routine testing), the numbers they test and HIV infections they identify are equal to or surpass benchmarks in community-based settings.(35, 38, 42)

A major consideration in the effectiveness of ED-based HIV testing is for patients to actually receive their results and be connected to care. When follow-up is required - such as when providers refer patients to outpatient HIV testing or when patients have to return for test results - adherence is poor and testing is ineffective.(27, 32) Intensive follow-up with patients to deliver test results is one approach that has been effective.(36) Another is the use of rapid HIV tests in which results can be available at a single visit. Rates of patient consent to rapid testing are comparable to those for standard testing.(20)

Cited Sources

Current Recommendations

HIV infection is consistent with all generally accepted criteria that justify screening:(4)

1. It is a serious health disorder that can be diagnosed before symptoms develop;
2. It is detectable by reliable, inexpensive, and noninvasive screening tests;
3. Infected patients can have years of life to gain if treatment is initiated early, before symptoms develop;
4. The costs of screening are reasonable in relation to the anticipated benefits.(43)

The U.S. Preventive Services Task Force recommends routine screening for patients at increased risk for HIV.(44) In 2006, the CDC expanded its recommendation for HIV screening in health care settings to include all patients ages 13 to 64, regardless of risk. The rationale for this new recommendation stems from evidence that people with HIV infection visit health-care settings years before receiving a diagnosis, but are not tested for HIV.(26, 45, 46) In addition, patients with unrecognized HIV often deny all risk factors, even when systematically assessed.(24, 26) An increasing number of new HIV infections are found among people younger than 20 years old, women, members of racial and ethnic minority groups, people who reside outside metropolitan areas, and heterosexual men and women who are often unaware that they are at increased risk for HIV.(4, 47) Missed diagnoses, denial of risk factors, and the changing demographics of HIV indicate that the effectiveness of risk-based testing may be diminishing.

Cited Sources

4. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. Sept 22, 2006;55(RR-14):1-17.
24. Kelen GD, Hexter DA, Hansen KN, Tang N, Pretorius S, Quinn TC. Trends in human immunodeficiency virus (HIV) infection among a patient population of an inner-city emergency department: implications for emergency department-based screening programs for HIV infection. Clinical Infectious Diseases. Oct 1995;21(4):867-875.
26. Alpert PL, Shuter J, DeShaw MG, Webber MP, Klein RS. Factors associated with unrecognized HIV-1 infection in an inner-city emergency department. Annals of Emergency Medicine. Aug 1996;28(2):159-164.
43. Wilson JM, Jungner G. Principles and practice of screening for disease. Geneva, Switzerland: World Health Organization; 1968.
44. U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. Accessed May 3, 2007.
45. Klein D, Hurley LB, Merrill D, Quesenberry CP Jr., Research Cf HIVAI. Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection. Journal of Acquired Immune Deficiency Syndromes. Feb 1 2003;32(2):143-152.
46. Liddicoat RV, Horton NJ, Urban R, Maier E, Christiansen D, Samet JH. Assessing missed opportunities for HIV testing in medical settings. Journal of General Internal Medicine. Apr 2004;19(4):349-356.
47. Institute of Medicine. No time to lose: getting more from HIV prevention. Washington, DC 2001.

Selected Bibliography

1. Hogg RS, Heath KV, Yip B, et al. Improved survival among HIV-infected individuals following initiation of antiretroviral therapy.[see comment]. JAMA. Feb 11 1998;279(6):450-454.
2. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. National HIV Prevention Conference. Atlanta, GA; 2005.
3. Centers for Disease Control and Prevention. HIV/AIDS surveillance report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2005.
4. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. Sept 22, 2006;55(RR-14):1-17.
5. Marks G, Crepaz N, Janssen R. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. June 26 2006;20(10):1447-1450.
6. Marks G, Crepaz N, Senterfitt J, Janssen R. 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;39:446-453.
7. Palella F, Deloria-Knoll M, Chmiel J, et al. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Ann Intern Med 2003;138:620-626.
8. Colfax GN, Buchbinder SP, Cornelisse PGA, Vittinghoff E, Mayer K, Celum C. Sexual risk behaviors and implications for secondary HIV transmission during and after HIV seroconversion. AIDS. Jul 26 2002;16(11):1529-1535.
9. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. New England Journal of Medicine. Mar 30 2000;342(13):921-929.
10. Paltiel AD, Walensky RP, Schackman BR, et al. Expanded HIV screening in the United States: Effect on clinical outcomes, HIV transmission and costs. Annals of Internal Medicine. 2006;145:797-806.
11. Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States - an analysis of cost-effectiveness. New England Journal of Medicine. Feb 10 2005;352(6):586-595.
12. Sanders GD, Bayoumi AM, Sundaram V, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. New England Journal of Medicine. Feb 10 2005;352(6):570-585.
13. Levi J, Kates J. HIV: challenging the health care delivery system. Am J Public Health. July 2000;90(7):1033-1036.
14. Centers for Disease Control and Prevention. Questions and Answers for Professional Partners: Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Healthcare Settings. Accessed May 3, 2007.
15. Kaiser Family Foundation. Financing HIV/AIDS Care: A Quilt with Many Holes May 2004.
16. Medical Access Study Group. Nowhere to go: Medicaid patient access to primary care. New Eng J Med. 1994;330:1426-1430.
17. Sox C, Swartz K, Burstin H, Brennan T. Insurance or regular physician: Which is the most powerful predictor of health care. American Journal of Public Health. 1999;88(3):364-370.
18. Sue D, Shahan J, Kelen G. Primary care access for Medicaid versus privately insured patients. Acad Emerg Med. 1994;1:A1.
19. Zuvekas S, Weinick R. Changes in access to care, 1977-1996: The role of health insurance. Health Services Research. 1999;34(1):271.
20. Kelen GD, Shahan JB, Quinn TC. Emergency department-based HIV screening and counseling: experience with rapid and standard serologic testing. Annals of Emergency Medicine. Feb 1999;33(2):147-155.
21. Rothman RE, Ketlogetswe KS, Dolan T, Wyer PC, Kelen GD. Preventive care in the emergency department: should emergency departments conduct routine HIV screening? a systematic review. Academic Emergency Medicine. Mar 2003;10(3):278-285.
22. Schoenbaum E, Webber MP. The underrecognition of HIV infection in women in an inner-city emergency room. American Journal of Public Health. 1993;83:363-368.
23. Lindsay M, Grant J, Peterson H, Risby J, et al. Human immunodeficiency virus infection among patients in a gynecology emergency department. Obstetrics & Gynecology. 1993;81:1012-1015.
24. Kelen GD, Hexter DA, Hansen KN, Tang N, Pretorius S, Quinn TC. Trends in human immunodeficiency virus (HIV) infection among a patient population of an inner-city emergency department: implications for emergency department-based screening programs for HIV infection. Clinical Infectious Diseases. Oct 1995;21(4):867-875.
25. Kelen GD, Hexter DA, Hansen KN, et al. Feasibility of an emergency department-based, risk-targeted voluntary HIV screening program. Annals of Emergency Medicine. Jun 1996;27(6):687-692.
26. Alpert PL, Shuter J, DeShaw MG, Webber MP, Klein RS. Factors associated with unrecognized HIV-1 infection in an inner-city emergency department. Annals of Emergency Medicine. Aug 1996;28(2):159-164.
27. Goggin MA, Davidson AJ, Cantril SV, O'Keefe LK, Douglas JM. The extent of undiagnosed HIV infection among emergency department patients: results of a blinded seroprevalence survey and a pilot HIV testing program. Journal of Emergency Medicine. Jul 2000;19(1):13-19.
28. Williams Torres G, Hasnain-Wynia R, Whitmore H, Pickreign J, Stanger JK. Hospital HIV Testing Policies and Practices: A National Survey: Health Research and Educational Trust; 2005.
29. Wilson SR, Mitchell C, Bradbury DR, Chavez J. Testing for HIV: current practices in the academic ED. American Journal of Emergency Medicine. Jul 1999;17(4):354-356.
30. Fincher-Mergi M, Cartone KJ, Mischler J, Pasieka P, Lerner EB, Billittier A. Assessment of emergency department health care professionals' behaviors regarding HIV testing and referral for patients with STDs. AIDS Patient Care & Stds. Nov 2002;16(11):549-553.
31. Centers for Disease Control and Prevention. Routinely recommended HIV testing at an urban urgent-care clinic - Atlanta, Georgia, 2000. Morbidity and Mortality Weekly Report. 2001;50(25):538.
32. Coil CJ, Haukoos JS, Witt MD, Wallace RC, Lewis RJ. Evaluation of an emergency department referral system for outpatient HIV testing. Journal of Acquired Immune Deficiency Syndromes: JAIDS. Jan 1 2004;35(1):52-55.
33. Glick NR, Silva A, Zun L, Whitman S. HIV testing in a resource-poor urban emergency department. AIDS Education and Prevention. 2004;16(2):126.
34. Haukoos JS, Witt MD, Zeumer CM, Lee TJ, Halamka JD, Lewis RJ. Emergency department triage of patients infected with HIV. Academic Emergency Medicine. 2002;9(9):880.
35. Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Health department collaboration with emergency departments as a model for public health programs among at-risk populations. Public Health Reports. May-June 2005;120:259-265.
36. Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Emergency department HIV testing and counseling: an ongoing experience in a low-prevalence area. Annals of Emergency Medicine. Jul 2005;46(1):22-28.
37. Lyss SB, Branson BM, Kroc KA, Couture EF, Newman DR, Weinstein RA. Detecting unsuspected HIV infection with a rapid whole-blood HIV test in an urban emergency department. J Acquir Immune Defic Syndr. 2007;44(4):435-442.
38. Walensky RP, Losina E, Malatesta L, et al. Effective HIV case identification through routine HIV screening at urgent care centers in Massachusetts. American Journal of Public Health. Jan 2005;95(1):71-73
39. Paul SM, Cadoff E, Martin E, et al. Rapid HIV Testing in Emergency Departments: A Successful New Jersey Initiative. Prevention Health Week. New Brunswick; 2005.
40. Randall L. Personal communication. Michigan Department of Community Health; 2006: Key informant interview.
41. 2007 Society for Academic Emergency Medicine Annual Meeting Abstracts. Academic Emergency Medicine. 2007;14(5, Supplement 1).
42. Kendrick SR, Kroc KA, Couture E, Weinstein RA. Comparison of point-of-care rapid HIV testing in three clinical venues. AIDS. Nov 5 2004;18(16):2208-2210.
43. Wilson JM, Jungner G. Principles and practice of screening for disease. Geneva, Switzerland: World Health Organization; 1968.
44. U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. Accessed May 3, 2007.
45. Klein D, Hurley LB, Merrill D, Quesenberry CP Jr., Research Cf HIVAI. Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection. Journal of Acquired Immune Deficiency Syndromes. Feb 1 2003;32(2):143-152.
46. Liddicoat RV, Horton NJ, Urban R, Maier E, Christiansen D, Samet JH. Assessing missed opportunities for HIV testing in medical settings. Journal of General Internal Medicine. Apr 2004;19(4):349-356.
47. Institute of Medicine. No time to lose: getting more from HIV prevention. Washington, DC 2001.
48. Chen Z, Branson B, Ballenger A, Peterman TA. Risk assessment to improve targeting of HIV counseling and testing services for STD clinic patients. Sex Transm Dis 1998;25:539--43.
49. CDC. Voluntary HIV testing as part of routine medical care---Massachusetts, 2002. MMWR 2004;53:523--6.
50. CDC. HIV prevalence, unrecognized infection, and HIV testing among men who have sex with men---five U.S. cities, June 2004--April 2005. MMWR 2005;54:597--601.
51. CDC. Anonymous or confidential HIV counseling and voluntary testing in federally funded testing sites---United States, 1995--1997. MMWR 1999;48:509--13.

Resources

Resources

• Reports, fact sheets, and slide sets from the CDC
• Hospital HIV Testing Policies and Practices, A National Survey (PDF)
  This summary covers findings of HRET's 2004 survey of U.S. hospitals.
• The HIV/AIDS Epidemic in the United States (PDF)
  HIV/AIDS Policy Fact Sheet. The Henry J. Kaiser Family Foundation, November 2006.
• Web Addresses for Reports of State or Local HIV and AIDS Surveillance (PDF)
• Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2005. Vol. 17. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2006 (PDF).
• Tutorial: Women and HIV/AIDS in the United States
  kaiserEDU.org, June 2007.