Routine HIV Screening in North Carolina in the Era of the Affordable Care Act Update on Laws, Reimbursement, and Tests

Authors: Becky L. White MD, MPH, Yvonne L. Carter MD, MPH, Katherine Records MPH, JD, Ian B.K. Martin, MD


Eighteen percent of the 1.2 million human immunodeficiency virus (HIV)–infected individuals in the United States are undiagnosed, with North Carolina accounting for the eighth largest number of new HIV diagnoses in 2011. In an effort to identify more HIV-infected individuals by reducing physician barriers to HIV testing, the Centers for Disease Control and Prevention have expanded their HIV screening recommendations to adolescents and adults without HIV risk factors or behaviors, eliminated federal requirements for pretest counseling, and modified the informed consent process. In 2010, the Office of National AIDS (acquired immunodeficiency syndrome) Policy released the first-ever national HIV/AIDS strategy, with the goal of reducing new infections, increasing access to care, improving HIV outcomes, and reducing HIV racial/ethnic disparities. In 2013, the US Preventive Services Task Force released A-level recommendations recommending nonrisk-based HIV screening for adults and adolescents that are consistent with the recommendations of the Centers for Disease Control and Prevention. In concert with these federal recommendations, the majority of states have modified their consent and counseling requirements. The implementation of the Patient Protection and Affordable Care Act will add requirements and incentives for federal (Medicare), state (Medicaid), and private (insurance) payers to reimburse physicians and patients for nonrisk-based HIV screening.

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1. Kates J, Carbaugh A, Rousseau D, et al. HIV/AIDS: the state of the epidemic after 3 decades. JAMA. 2012; 308: 330
2. Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 U.S. dependent areas–2010. Accessed April 4, 2013.
3. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006; 55: 1–17.
4. White House Office of National AIDS Policy. National HIV/AIDS strategy. Federal implementation plan. Published July 2012. Accessed September 25, 2013.
5. Moyer VA. U.S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013; 159: 51–60.
6. Neff S, Goldschmidt R. Centers for Disease Control and Prevention 2006 human immunodeficiency virus testing recommendations and state testing laws. JAMA. 2011; 305: 1767–1768.
7. Jain CL, Wyatt CM, Burke R, et al. Knowledge of the Centers for Disease Control and Prevention’s 2006 routine HIV testing recommendations among New York City internal medicine residents. AIDS Patient Care STDs. 2009; 23: 167–176.
8. Cohan D, Gomez E, Dowling T, et al. HIV testing attitudes and practices among clinicians in the era of updated Centers for Disease Control and Prevention recommendations. J Acquir Immune Defic Syndr. 2009; 50: 114–116.
9. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006; 20: 1447–1450.
10. Centers for Disease Control and Prevention (CDC). HIV surveillance—United States, 1981–2008. MMWR Morb Mortal Wkly Rep. 2011; 60: 689–693.
11. Mermin J, Fenton KA. The future of HIV prevention in the United States. JAMA. 2012; 308: 347–348.
12. Penner M, Leone PA . Integration of testing for, prevention of, and access to treatment for HIV infection: state and local perspectives. Clin Infect Dis. 2007; 45: S281–S286.
13. North Carolina epidemiologic profile for HIV/STD prevention & care planning. Published 2011. Accessed August 12, 2012.
14. Adimora AA, Schoenbach VJ. Contextual factors and the black-white disparity in heterosexual HIV transmission. Epidemiology. 2002; 13: 707–712.
15. Centers for Disease Control and Prevention. Missed opportunities for earlier diagnosis of HIV infection—South Carolina, 1997–2005. MMWR Morb Mortal Wkly Rep. 2006; 55: 1269–1272.
16. FDA approves first drug for reducing the risk of sexually acquired HIV infection. Published 2012. Accessed April 10, 2013.
17. Centers for Disease Control and Prevention. Interim guidance for clinicians considering the use of preexposure prophylaxis for the prevention of HIV infection in heterosexually active adults. MMWR Morb Mortal Wkly Rep. 2012; 61: 586–589.
18. Panel on Antiretroviral Guidelines for Adults and Adolescents, US Department of Health and Human Services. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Published 2012. Accessed December 21, 2012).
19. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011; 365: 493–505.
20. Sanders GD, Bayoumi AM, Sundaram V, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med. 2005; 352: 570–585.
21. Walensky RP, Weinstein MC, Kimmel AD, et al. Routine human immunodeficiency virus testing: an economic evaluation of current guidelines. Am J Med. 2005; 118: 292–300.
22. National HIV/AIDS Clinicians’ Consultation Center (NCCC). San Francisco General Hospital, University of California, San Francisco. Compendium of state HIV testing laws. Quick reference guide for clinicians. Published 2011. Accessed December 19, 2012.
23. Chou R, Selph S, Dana T, et al. Screening for HIV: systematic review to update the 2005 U.S. Preventive Services Task Force recommendation. Ann Intern Med. 2012; 157: 706–718.
24. Committee on Pediatric AIDS, Emmanuel PJ, Martinez J . Adolescents and HIV infection: the pediatrician’s role in promoting routine testing. Pediatrics. 2011; 128: 1023–1029.
25. HIV infection, adolescents and adults. Published 2013. Accessed August 23, 2013.
26. Qaseem A, Snow V, Shekelle P, et al. Screening for HIV in health care settings: a guidance statement from the American College of Physicians and HIV Medicine Association. Ann Intern Med. 2009; 150: 125–131.
27. American College of Emergency Physicians. Policy statement. HIV testing and screening in the emergency department. Ann Emerg Med. 2007; 50: 209
28.  American College of Obstetrics and Gynecology. Committee opinion no. 411. Routine human immunodefiency virus screening. Published 2008, reaffirmed 2010. Accessed August 23, 2013.
29. Institute of Medicine. Clinical preventive services for women: closing the gaps. Published July 19, 2011. Accessed September 25, 2013.
30. Burke RC, Sepkowitz KA, Bernstein KT, et al. Why don’t physicians test for HIV? A review of the US literature. AIDS. 2007; 21: 1617–1624.
31. National coverage determination (NCD) for screening for the human immunodeficiency virus (HIV) infection (210.7). Published 2009. Accessed January 14, 2013.
32. State Medicaid coverage of routine HIV screening. Published 2012. Accessed December 19, 2012.
33. Patient Protection and Affordable Care Act, tit. IV, § 4106(b), 42 USC § 1396(d) (2010).
34. Patient Protection and Affordable Care Act, tit. I, § 2713(a)(1), 42 USC §§ 300gg-13 (2010).
35. AMA and AAHIVM releases coding guidelines for routine HIV testing. Published September 28, 2008. Accessed September 25, 2013.
36. Bartlett J. Serologic screening for HIV infection. Published July 11, 2013. Accessed September 25, 2013.
37. US Food and Drug Administration. FDA approves first over-the-counter home-use rapid HIV test. Published July 3, 2012. Accessed July 24, 2012.
38. Branson BM, Stekler JD. Detection of acute HIV infection: we can’t close the window. J Infect Dis. 2012; 205: 521–524.