Revised Guidelines for HIV Counseling,Testing, and ...

1 November 9, 2001 / Vol. 50 / No. RR-19. Nurses and Nurses recommendations and Physicians and Reports for Physicians Revised Guidelines for HIV counseling , Education Testing, and Referral Education Education for and Continuing Medical Medical Revised recommendations for HIV screening Inside: Two of Pregnant Women Continuing Inside: Continuing DEPARTMENT OF HEALTH AND HUMAN SERVICES. Centers for Disease Control and Prevention (CDC). Atlanta, GA 30333. Inside: The MMWR series of publications is published by the Epidemiology Program Office, Centers for Disease Control and Prevention (CDC), Department of Health and Human Services, Atlanta, GA 30333. SUGGESTED CITATION. Centers for Disease Control and Prevention. Revised Guidelines for HIV counseling , Testing, and Referral and Revised recommendations for HIV screening of Pregnant Women. MMWR 2001;50(No. RR-19):[inclusive page numbers]. Centers for Disease Control and Prevention .. Jeffrey P. Koplan, , Director The material in this report was prepared for publication by National Center for HIV, STD, and TB Prevention.

2 Harold W. Jaffe, Acting Director Division of HIV/AIDS Prevention Surveillance and Epidemiology .. Robert S. Janssen, Director The production of this report as an MMWR serial publication was coordinated in Epidemiology Program Office .. Barbara R. Holloway, Acting Director Office of Scientific and Health Communications .. John W. Ward, Director Editor, MMWR Series recommendations and Reports .. Suzanne M. Hewitt, Managing Editor .. Amanda Crowell Project Editor .. Lynda G. Cupell Visual Information Specialist .. Michele D. Renshaw Erica R. Shaver Information Technology Specialists Vol. 50 / No. RR-19 MMWR i Contents Revised Guidelines for HIV counseling , Testing, and Referral .. 1. Introduction .. 1. Targeted Versus Routinely Recommended HIV CTR .. 7. HIV counseling .. 13. HIV Testing .. 27. HIV Referral .. 36. HIV CTR Services in Nontraditional Settings .. 39. Quality Assurance and Evaluation of HIV CTR Services .. 43. Conclusion .. 45. Additional Resources.

3 45. References .. 46. Glossary .. 54. Continuing Education Examination .. CE-1-19a1. Revised recommendations for HIV screening of Pregnant Women .. 59. Introduction .. 63. Background .. 65. recommendations .. 75. Conclusions .. 81. References .. 81. Continuing Education Examination .. CE-1-19a2. ii MMWR November 9, 2001. Vol. 50 / No. RR-19 MMWR iii Notice to Readers This MMWR contains two articles, each with a continuing education examination. Each examination is printed on blue paper and placed directly after its accompanying article. The first examination is labeled RR-19a1, and the second is labeled RR-19a2. Please make sure you complete and submit the correct response form for the article for which you want to receive continuing education credit. You may take both examinations and receive credit for both articles. iv MMWR November 9, 2001. Technical Expert Panel Review of CDC. HIV counseling , Testing, and Referral Guidelines February 18 19, 1999.

4 Atlanta, Georgia Terje J. Anderson Cynthia A. Getty National Association of People with AIDS CDC. Washington, Atlanta, Georgia David Atkins, , Lawrence O. Gostin, , Agency for Healthcare Research and Quality Georgetown University Rockville, Maryland Washington, Catherine Baker-Cirac Khurram S. Hassan, California Office of AIDS United Way of Metro Atlanta Sacramento, California Atlanta, Georgia Ronald Bayer, Thomas L. Hearn, , Columbia University CDC. New York, New York Atlanta, Georgia Frank K. Beadle de Palomo, Michael P. Johnson, , Academy for Educational Development Health Resources and Services Washington, Administration Rockville, Maryland Gail A. Bolan, California Department of Health William J. Kassler, , Berkeley, California New Hampshire Department of Health & Human Services Carol A. Browning, Concord, New Hampshire Rhode Island Department of Health Providence, Rhode Island Marlene LaLota, Florida Department of Health Scott Burris, Tallahassee, Florida Temple University Philadelphia, Pennsylvania Michael K.

5 Lindsay, , Emory University Amy S. DeGroff, Atlanta, Georgia Centers for Disease Control and Prevention (CDC) Michael H. Merson, Atlanta, Georgia Yale University New Haven, Connecticut John M. Douglas, Denver Public Health Stephen F. Morin, , Denver, Colorado University of California, San Francisco San Francisco, California Martin Fishbein, University of Pennsylvania James Pearson, , Philadelphia, Pennsylvania Division of Consolidated Laboratory Services Alice A. Gandelman, Richmond, Virginia California STD Control Branch Berkeley, California Beny J. Primm, Urban Resources Institute Brooklyn, New York Vol. 50 / No. RR-19 MMWR v Joel Rosenstock, , Infectious Disease Solutions, Atlanta, Georgia Peter Salovey, Yale University New Haven, Connecticut Charles A. Schable, CDC. Atlanta, Georgia Kathleen J. Sikkema, Yale University New Haven, Connecticut Edith Springer, Edith Springer Associates Brooklyn, New York Janis Spurlock-McLendon, Connecticut Department of Public Health Hartford, Connecticut Lee Trevithick, Cocoon House Everett, Washington James Welch Division of Public Health Dover, Delaware vi MMWR November 9, 2001.

6 The following CDC staff members prepared this report: Beatrice T. Divine, Stacie M. Greby, , Kenneth V. Hunt Mary L. Kamb, , Richard W. Steketee, , Lee Warner, Division of HIV/AIDS Prevention Surveillance and Epidemiology National Center for HIV, STD, and TB Prevention in consultation with Liisa M. Randall, National Alliance of State and Territorial AIDS Directors Vol. 50 / No. RR-19 MMWR 1. Revised Guidelines for HIV counseling , Testing, and Referral Summary These Guidelines replace CDC's 1994 Guidelines , HIV counseling , Testing, and Referral Standards and Guidelines , and contain recommendations for public- and private-sector policy makers and service providers of human immunodeficiency virus (HIV) counseling , testing, and referral (CTR). To develop these Guidelines , CDC used an evidence-based approach advocated by the Preventive Services Task Force and public health practice Guidelines . The recommendations are based on evidence from all available scientific sources; where evidence is lacking, opinion of best practices by specialists in the field has been used.

7 This revision was prompted by scientific and programmatic advances in HIV. CTR, as well as advances in prevention and the treatment and care of HIV-infected persons. These advances include a) demonstrated efficacy of HIV prevention counseling models aimed at behavioral risk reduction; b) effective treatments for HIV infection and opportunistic infections; c) effective treatment regimens for preventing perinatal transmission; and d) new test technologies. Although the new Guidelines include many aspects of the previous ones ( , encouragement of confidential and anonymous voluntary HIV testing, need for informed consent, and provision of HIV prevention counseling that focuses on the client's own risk), the new Guidelines differ in several respects, including giving guidance to all providers of voluntary HIV CTR in the public and private sectors;. using an evidence-based approach to provide specific recommendations for CTR;. underscoring the importance of early knowledge of HIV status and making testing more accessible and available.

8 Acknowledging providers' need for flexibility in implementing the Guidelines , given their particular client base, setting HIV prevalence level, and available resources;. recommending that CTR be targeted efficiently through risk screening and other strategies; and addressing ways to improve the quality and provision of HIV CTR. INTRODUCTION. Purpose of the Guidelines These Guidelines were developed for policy makers and service providers in the many settings that offer voluntary human immunodeficiency virus (HIV) counseling , testing, and referral (CTR) public and private, urban and rural, and those with high and low HIV prevalence (Box 1). The Guidelines are intended to be used to develop CTR. services and policies in traditional clinical settings ( , sexually transmitted disease 2 MMWR November 9, 2001. BOX 1. HIV counseling , testing, and referral (CTR) settings Settings that provide HIV CTR include but are not limited to the following traditional clinical and nontraditional settings: Adolescent health Family planning clinics Outreach programs clinics, school-based ( , syringe ex- Freestanding HIV test health centers, change programs).)

9 Sites university health Prenatal clinics centers Hospital emergency departments Private-sector AIDS services service providers organizations Hospitals/other urgent care centers Publicly funded Clinics serving men counseling and who have sex with Managed care organi- testing sites men zations Sexually transmitted Community-based Men's health clinics disease clinics organizations Migrant health centers Tuberculosis clinics Community health centers Occupational/employee Women's health clinics health clinics Correctional facilities Drug or alcohol prevention and treatment programs [STD] clinics, private physicians' offices) and nontraditional settings ( , community- based or outreach settings [homeless shelters, bars]), which can be important places to provide access to CTR to persons at increased HIV risk. The Public Health Service is responsible for ensuring the quality of services in publicly funded programs, and many aspects of these Guidelines focus on such programs.

10 The Guidelines could also be useful for CTR in other settings ( , for insurance, military, and blood donation purposes). recommendations should be tailored to fit the needs of clients, communities, and pro- grams within local, state, and federal rules and regulations. Evolution of the Guidelines These Guidelines revise and update several sets of CDC Guidelines for HIV CTR. The first CDC Guidelines , published in 1986, highlighted the importance of offering voluntary testing and counseling and maintaining confidential records (1 ). In 1987, new Guidelines emphasized the need to decrease barriers to counseling and testing, especially disclo- sure of personal information (2 ). In 1993, an additional report described the model of HIV. prevention counseling currently recommended an interactive rather than didactic model focusing on a personalized HIV risk-reduction plan (3 ). In 1994, HIV counseling , Testing and Referral Standards and Guidelines focused on standard counseling and test- ing procedures and reiterated the importance of the HIV prevention counseling model and the need for confidentiality of counseling (4 ).