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WHY SCREENING
Routine screening for HIV can save lives, just like routine
screening for colon cancer, breast cancer or heart disease.
Just like these conditions, HIV can be detected before
symptoms appear, thereby gaining a patient years of life if
treatment is started early. Just like these conditions, treatment
of HIV is more difficult once symptoms appear. Just like these
conditions, the costs of screening are reasonable in relation
to the anticipated benefits.
Among pregnant women, screening has proven substantially
more effective than risk-based testing for detecting
unsuspected maternal HIV infection and preventing
perinatal transmission.
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OVERVIEW OF
ROUTINE HIV SCREENING
Routine HIV screening in primary care is important because
risk-based assessments may miss patients with HIV infection.4
Routine HIV Screening
The Maryland Department of Health and Mental Hygiene,
the Centers for Disease Control and Prevention and the
US Preventive Services Task Force recommend that all health
care professionals: “in all health care settings(e.g. hospitals,
urgent care or emergency departments, inpatient services,
community health centers and clinics, correctional healthcare
facilities, and primary care settings) offer diagnostic HIV
testing and HIV screening as part of routine clinical care
for individuals ages 13–65.” 3
High risk patients who fall outside this age range should also
be screened.
All pregnant women, regardless of risk factors, should be
screened for HIV. (See Frequency of HIV Screening).
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OVERVIEW OF ROUTINE
HIV SCREENING CONTINUED
HIV Screening for High Risk
and Vulnerable Individuals
If an individual is known to
be at high risk for HIV, he or
she should be screened at
least annually, ideally every
three months.
Examples of individuals who
may be at high risk include:
patients being treated for other
STIs (Sexually Transmitted
Infections), injection-drug users
and their sex partners, persons
who exchange sex for money/
drugs, men who have sex with
men, persons who themselves or
whose partners have had more
than one sex partner since their
most recent HIV test,
sex/needle sharing partners of
HIV-infected persons,3 patients
with tuberculosis.
Types of Tests
HIV infection is diagnosed with
1) a rapid screen on site or
2) an Enzyme-linked
immunosorbent assay(ELISA)
with confirmation by
Western blot or indirect
immunofluorescence assay.
Acute HIV infection requires
a plasma HIV RNA test to detect
viral load.
The tests each offer different
advantages. Rapid tests can be
well-suited for patients that might
not return to get the results.
See chart on page 31 for more
detail about types of HIV tests.
Screening for Acute (Recent)
HIV Infection
Acute HIV infection is the period
of time immediately following
infection prior to the presence of
antibodies. This period between
infection and the presence of
antibodies is the window period
(see graph on page 31). If a
patient presents with flu-like
symptoms and has a history
of high risk behaviors, suspect
acute HIV infection. These
cases are quite rare. Both an
HIV RNA(viral load) test and an
antibody test are required when
acute HIV infection is suspected
(See Recent HIV Infection later in
this section).
Retention in Care for HIV
Infected Individuals
Reassure patients that
adherence to antiretroviral (ART)
medications will allow them to
live a long and productive life.
The belief that HIV infection
quickly leads to death can hinder
patients’ motivation to change
high-risk behaviors such as
unsafe sex and needle sharing.
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FREQUENCY OF HIV SCREENING
Ages 13-65 Years
The U.S. Centers for Disease Control and Prevention (CDC)
recommends screening all patients and repeating screening
annually, if the patients are engaged in any ongoing risky behavior
associated with HIV infection, including unprotected sex.
Patients with Risk Factors Listed Below
The Baltimore City Health Department recommends that the following
patients be tested at least annually, ideally every 3 months:
Injection drug users(IDUs) and their sex partners • People who exchange
sex for money or drugs • Men who have sex with men (MSM) •
Heterosexual individuals who have had, or whose sex partners have had,
more than one sex partner since their most recent HIV test • Sex/needle
sharing partners of HIV-infected persons
Patients with Symptoms and Signs of Acute HIV Infection
Patients presenting with flu-like symptoms(below) and have a history
of high risk behaviors should be tested with BOTH an antibody and
plasma HIV RNA test.5 Symptoms may include: Fever • Malaise •
Rash • Pharyngitis • Lymphadenopathy • Aseptic meningitis
Pregnant Patients
Screen as early as possible during pregnancy. Maryland state law
requires HIV screening as a part of the routine prenatal blood
screens unless the patient opts out. HIV screening should be offered in
the third trimester of pregnancy and during labor and delivery for patients
with an unknown or undocumented HIV status.6
Patients Seeking Treatment for Sexually Transmitted
Infections (STIs): See Appendix
Patients with Tuberculosis
Screen all patients initiating TB treatment for HIV. Screen annually, or
every three months if they are engaged in any of the above risk behaviors.
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RECENT(ACUTE)
HIV INFECTION
As many as 50% of HIV transmissions occur during the acute
and early stages of the illness7
Acute HIV Infection Defined
Acute HIV infection is the period immediately following infection with
HIV, prior to the appearance of HIV antibodies. This period usually lasts
6 to 8 weeks. During this time, the level of virus increases rapidly in the
blood. Between 5 and 30 days after infection, flu-like symptoms (fever,
malaise, lymphadenopathy, rash) can appear and last for several weeks.
Suspect acute HIV infection if a patient presents with flu-like symptoms
and history of high risk behaviors. Acute HIV infection is also called
Primary HIV infection, early or recent HIV infection, acute retroviral
syndrome and acute HIV syndrome.
Transmission and Acute HIV Infection
Patients with acute HIV infection are at particularly high risk of
transmitting HIV because of the high viral levels.
Testing and Acute HIV Infection
Finding a patient in the acute stage of HIV infection is a rare event. HIV
antibodies can take up to three months to appear. Most standard HIV
tests such as a rapid HIV test or ELISA/Western Blot tests respond to
HIV antibodies. Patients with acute HIV infection will generally receive
negative or indeterminate results from these two types of tests. If acute
HIV is suspected, use an HIV RNA test in combination with an
HIV-1 antibody test.5 The HIV RNA test can detect HIV viral load; a
high viral load is indicative of HIV infection (see Providing Test
Results in Section 4).
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TYPES OF HIV TESTS
TEST TYPES
ELISA (Enzyme
Plasma HIV RNA
HIV-1/2 Ag/Ab
(viral load test)
(4th Generation)
Rapid Test
linked immune
absorbent assay)
Western Blot
Initial HIV screening
Initial HIV screening
Confirmatory test
Identify acute/recent
HIV infection
DETECTS
HIV antibodies
HIV antibodies
HIV antibodies
Amount of HIV (viral
load) in the blood.
HIV-1 and HIV-2
Antibodies, HIV-1 p24
Antigen
SOURCE OF
SAMPLE
Finger prick or
oral fluids
Blood, urine or
oral fluids
Blood
Blood
Blood
PROCESSED
BY A LAB
No
Yes
Yes
Yes, may require
specialized lab
Yes
TIME FOR
RESULTS
20 minutes or less
2—14 days
2–14 days
1–3 weeks
USE
Identify HIV infections
(Acute infections are determined if
HIV RNA is reactive)
Up to 1 hour
(Additional testing
needed, if reactive)
Testing Timeline
Source: Centers for Disease
Control and Prevention and
Association of Public Health
Laboratories. Laboratory
Testing for the Diagnosis
of HIV Infection: Updated
Recommendations. Available
at http://stacks.cdc.gov/
view/cdc/23447. Published
June 27, 2014. Accessed
November 1, 2015.
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PRE–TEST INFORMATION
AND PATIENT CONSENT
As of July 1, 2015, HIV testing in health-care settings is optout. Patients must be informed that they will be screened
for HIV along with routine blood tests unless they decline
to have the test. Before undergoing HIV testing, pre-test
information must be provided to the patient orally, in written
form, or by/through the use of videos. If a patient declines
HIV testing, it must be documented in the medical record.
*Providers working with
adolescent patients (<18 years)
should discuss that reproductive
health services may appear on an
explanation of benefits that their
parents or guardians could receive.
See appendix for considerations
unique to adolescent patients.
Pretest Information Must
Include:
An explanation of HIV infection;
The meaning of positive and
negative test results;
Their ability to ask questions
and to decline HIV testing.
Obtaining Informed Consent
When HIV testing is performed,
consent for HIV testing is
by law in Maryland (effective
7/1/2015) a part of the patient’s
general informed consent for
medical care as is done for other
screening and diagnostic tests
(i.e. Opt Out). This means that
HIV testing does not need to
be singled out in the general
consent form but rather it is
covered under the broader
general consent language for
services provided at the facility. A
health care provider may not be
required to obtain consent using
a separate form. Providers must
also inform the individual either
verbally or in writing that the test
will be performed unless they
decline.
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Patients under 18 can consent to
an HIV test and treatment.
Patients must be capable
of consenting.
Patients need to know they can
refuse an HIV test without penalty.
In non-health care settings, such
as venue testing or in Community
Based Organizations, consent
must be provided in writing. The
Health Department's HIV informed
consent form must be used.
HOW TO OFFER
A ROUTINE HIV TEST
Sample Script for Routine HIV Screening
As part of routine care, we screen all patients between 13 and 65
years of age for HIV at least once, whether or not they think they are
at risk.
*For minors,
remember to discuss
EOB documents as
a potential breach of
confidentiality.
We do this to help keep our patients healthy. There are excellent
treatment options and catching it early can be a life saver.
This pamphlet tells you about HIV and why you should be screened.
We are giving it to all our patients.
I would be glad to answer any questions you have. Like all medical
screens, the results will be confidential.*
You can decline the test and it will not affect the care you
receive today.
If patient declines:
Would you read the pamphlet about HIV and we’ll talk about it
next time?
Are there concerns you have about the test?
What NOT to Say:
If a patient asks for an HIV test, make sure NOT to...
» ask why
» act surprised
» ask what they have been up to
» dissuade them
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PART 3:
HOW TO BILL
HOW TO BILL:
CODING GUIDELINES
Medicare HCPCS codes
Test product
Code
G0432
G0433
G0435
Description
Infectious agent antigen detection by enzyme immunoassay (EIA) technique, qualitative or
semi-quantitative, multiple-step method, HIV-1 or HIV-2, screening
Infectious agent antigen detection by enzyme-linked immunosorbent assay (ELISA) technique,
antibody, HIV-1 or HIV-2, screening
Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or
HIV-2, screening
CPT ®codes
Test product
Code
86689
86701
86703
87534
Rapid test
modifier
92
92
87535
87536
87389
Description
Antibody; HTVL or HIV antibody, comfirmatory test (e.g, Western Blot)
Antibody; HIV-1
Antibody; HIV-1 and HIV-2, single assay
Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct
probe technique
Infectious agent detection by nucleic acid (DNA or RNA); HIV-1,
amplified probe technique
Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification
Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semi-quantitative, multiple-step method; HIV-1 antigen(s),
with HIV-1 and HIV-2 antibodies, single result
87390
92
Infectious agent antigen detection by enzyme immunoassay technique, qualita
tive or semi-quantitative, multiple step method; HIV-1
Code
36415
Description
Collection of venous blood by venipuncture
Code
99385
Description
Initial comprehensive preventive medicine service evaluation and management 18–39 years of age
(new patient)
Initial comprehensive preventive medicine service evaluation and management 40–64 years of age
(new patient)
Periodic comprehensive preventive medicine reevaluation and management 18–39 years of age
(established patient)
Periodic comprehensive preventive medicine reevaluation and management 40–64 years of age
(established patient)
Office or other outpatient visit for the evaluation and management of an established patient that
may not require the presence of a physician.
Test administration
Office service
99386
99395
99396
9921199215
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Case Scenario
The following guidelines are from the
AMA and the American Academy of
HIV Medicine to help providers bill for
HIV screening.
A private practice physician sees a 20-year-old single male for a
physical examination before his senior year of college. The patient, who
is not an established patient, has had multiple sexual partners, both
male and female. The physician performs the HIV rapid test. To bill use:
ICD-10-CM Diagnosis Codes
Z00.00 Encounter for routine general adult medical examination
Z11.4 Encounter for screening for human immunodeficiency virus (HIV)
Z72.89 Other problems related to lifestyle (since patient is
asymptomatic but in a known high risk group)
Z71.7 HIV Counseling (if counseling is provided during the encounter
for the test or after the results are available)
Z21 Asymptomatic HIV infection status if the results are positive but the
patient is asymptomatic
Z20.6 Contact with and (suspected) exposure to human
immunodeficiency virus (HIV)
Z79 Long term (current) drug therapy. Includes long term (current) drug
use for prophylactic purposes, PrEP, PEP, nPEP.
Z79.899 Other long term (current) drug therapy
B20 Human Immunodeficiency Virus [HIV] disease/returning patient
informed of his/her positive test result, AND patient is symptomatic.
CPT Codes
1. Test product
86701 with modifier 92 for the antibody HIV-1 test or
86702 with modifier 92 for the antibody HIV-1 and HIV-2 single assay
87389 for the HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies,
single result
2. Office service
» 99385 if the patient is new for initial comprehensive preventive
medicine service evaluation and management or
99395 if the patient is established for periodic comprehensive
preventive medicine reevaluation and management
» 99211-99215 for the evaluation and management of an
established patient if the results are positive and HIV
counseling is provided
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PART 4:
HOW TO PROVIDE
HIV TEST RESULTS
Positive test results must be given in person.
Preliminary positives must be confirmed.
A positive preliminary test and negative
Western Blot should be followed with plasma
HIV RNA testing to rule out acute infection.
When an individual receives a positive test
result, providers are required by law to refer the
individual to treatment and supportive services.
RAPID AND ELISA:
NEGATIVE
What it Means
This test did not find HIV antibodies in the blood. While this result
most likely means a patient does not have HIV, this test cannot detect
recent infection (i.e. exposure that occurred in the past 3 months).
Next Steps
If the patient has engaged in high risk activities in the past three months,
have them retested in three months.
If acute HIV suspected, order plasma HIV RNA test.
What to Say
If no high risk behavior:
“The results are negative. This almost always means you do not have
HIV. No further testing is needed unless you think you have been
exposed in the past three months. What questions do you have about
staying HIV negative?”
If high risk behavior:
“A negative test means you do not have HIV infection; however the test
may not show recent infection within the past 3 months. To be certain
that you do not have HIV, I recommend getting another test 3 months
after your last exposure. Can I help you figure out when that would be?
We can make an appointment for you based on that.”
If acute HIV suspected:
“Because of your symptoms, I’m going to use another way to
detect whether HIV is present. This test looks for the HIV virus in
your blood and is better at finding a recent infection.”
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RAPID AND ELISA:
INDETERMINATE
What it Means
An indeterminate test means that it cannot be determined from
the results whether the patient is HIV positive or negative.
Next Steps
Offer to test again.
If acute HIV suspected, order plasma HIV RNA test.
What to Say
“This test was neither positive nor negative. This happens sometimes
and could result for a number of reasons. We are going to test again to
try to get a clearer answer.”
If acute HIV suspected:
“Because of your symptoms, I’m going to use another way to detect
whether HIV is present. This test looks for the HIV virus in your blood
and is better at finding a recent infection.”
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RAPID AND ELISA:
POSITIVE
What it Means
The test detected HIV antibodies in the blood. This is a preliminary
positive test and an indication the patient has HIV. In order to
establish a confirmed positive, a confirmatory test needs to be
conducted, such as a Western Blot. In the case of a positive ELISA,
the lab should conduct this confirmatory test automatically. If the
result is from a rapid test, a confirmatory test needs to be ordered.
A confirmatory test does not occur automatically with a rapid test.
Next Steps
With positive rapid test, order confirmatory test; draw blood if needed
With positive ELISA, laboratory will automatically perform
confirmatory test
Inform patient of results in person in a private area
Give patient time to react to initial news
Emphasize confirmation is needed
Emphasize HIV is treatable
For pregnant patients:
Connect with HIV provider
Start combination ART treatment as soon as possible
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What to Say
“Your preliminary test result was positive.
This means you probably have HIV.
We won't know for sure if you are infected with HIV until we get the
results from your confirmatory test. However, it is very likely (99%) that
that test will be also be positive. It will take about 1-2 weeks to receive
these results.
It is important to return for the results of this test.”
“This is a serious infection, but people today are living longer healthier
lives with medication that can keep the immune system strong. It is
a good thing to know; this can get you on the path to treatment. HIV
is treatable. Knowing you have HIV can help you take precautions to
prevent passing it to others.”
“There are all kinds of support available and we will help connect you
to services that can help you through this.”
“How are you feeling? What are your questions?”
"What will you do after you leave here? Who will you talk to about this?"
For pregnant patients:
“ Your preliminary HIV screening result was positive. You may have
HIV infection. We need to do a second (or confirmatory) test, but it
is important to start medication to reduce the risk of passing HIV to
your baby while we wait for the result.”
If appropriate: “It is important to delay breast-feeding until we have
the second test result.”
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WESTERN BLOT:
NEGATIVE
What a Negative Western Blot Means
This test did not detect HIV antibodies in the blood and
most likely indicates original antibody results were false
positive. This test cannot detect infection that has occurred
in the last 12 weeks.
Next Steps
If no signs, symptoms or risk factors for HIV, share
negative results with patient.
If acute HIV infection suspected, order plasma HIV RNA
or retest in 6 weeks.
What to Say
If no signs, symptoms:
“The second test came back negative. No further testing is needed
unless you think you may have been exposed in the past three months.
We can test again in six weeks to make certain if you would like.”
If acute HIV is suspected:
“The second test was negative, but this test can’t always detect early
infection. Because of your symptoms, we are going to order another
test that works a different way to detect the virus.”
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WESTERN BLOT:
INDETERMINATE
What an Indeterminant Western Blot Means
An indeterminate test means that it cannot be
determined from the results whether the patient is HIV
positive or negative.
Next Steps
Repeat test in 6 weeks.
If acute HIV infection suspected, order plasma HIV RNA test
What to Say
“These test results were indeterminate. That means we could not tell
from this test whether you have HIV or not. We will need to retest in
6 weeks. Let’s schedule an appointment.”
If acute HIV is suspected:
“These results are indeterminate. That means the test does not
indicate whether you have HIV or not. Because of your symptoms,
I’m going to use another way to detect whether HIV is present. This
test looks for the HIV virus in your blood and is better at finding a
recent infection.”
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WESTERN BLOT :
POSITIVE
What a Positive Western Blot Means
In combination with a positive rapid or ELISA test, a positive
confirmatory test indicates infection with HIV. It does not
indicate the stage of disease.
Next Steps
Link Patient to HIV Primary Care
If the patient agrees to treatment, you are required by law to refer the
patient to care. There are several Baltimore City treatment and case
management centers that provide medical care and case management
services for HIV and AIDS patients (See HIV Treatment Providers list in
next section).
Provide Counseling
» Learning to Cope
Discuss ways to handle the emotional consequences of learning
about a positive test result.
» HIV is a Manageable Disease
Assure the patient that, with good medical care and patient adherence,
people with HIV stay healthier and live longer.
» Risk Reduction
Discuss how to prevent the spread of HIV to others.
» Partner Notification
Urge patients to notify their partners. See Partner Notification Options
in the next section.
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What to Say
In a private area alone with the patient
(unless patient requests presence of another person):
“These tests confirm that you have HIV infection.”
Allow patient time to react. Shock and disorientation are common
reactions. Remain calm and nonjudgmental. Pay attention to
the placement of chairs. Ensure that both you and client have
access to a door.
If appropriate, say “Tell me about your reaction. Is this a surprise
or something you were expecting?”
Even if patient does not show signs of shock or disorientation, do
not try to give too much information at once. Adjust accordingly
if concern exists that the patient will not return for more information.
Key next steps may need to be written down and supportive
material offered. Have up-to-date information on hand.
Offer reassurance that HIV does not mean AIDS and it is not a
death sentence:
“People with HIV who receive the care they need can live long
and healthy lives. With proper treatment you can as well. Even if
you don’t feel sick now, starting treatment right away will help
you in the long run.”
“What questions do you have now?”
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WESTERN BLOT:
POSITIVE CONTINUED
“It is normal to have more questions as time passes. Please
make sure you ask your health care providers.”
“There are all kinds of services and support in Baltimore to help
you through this. I will help link you with someone who can help
you take advantage of these resources.”
Talk to the patient about notification and reporting.
(see Notification in the next section)
“It will be important to notify sex partners so they can get tested,
too. I always encourage my patients to consider working with
the Health Department. They can notify your partners without
disclosing your identity. Someone from the Health Department
should be contacting you shortly.”
“The results of these tests will be kept confidential. According
to the law, we have to report any confirmed HIV cases to the
Health Department”
Get the patient connected to care; the more active referral the
better for the patient:
Make a phone call to make an appointment for the patient
while in the office.
If you are near a treatment center, see if a case manager can
help escort the patient there to get started.
The next section guides you through the steps of connecting
an HIV+ patient to care.
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PLASMA HIV RNA:
UNDETECTABLE
What it Means
No copies of the HIV virus were detectable in the blood. While
the results most likely mean the person does not have HIV, the
test can not detect virus levels in the first days of exposure.
Next Steps
Share results with patient
Offer antibody retest for concerned patients
For patients with high risk behaviors: Retest with
antibody test (rapid or ELISA) in 4-12 weeks
What to Say
For patients with no risk factors and negative antibody test:
“This test did not detect any virus in your blood. Most likely, this
means you do not have HIV. To be sure, we can schedule
another appointment to test for antibodies in 4-12 weeks.
Would you like to schedule an appointment?”
For patients with high risk behaviors:
“This test did not detect any virus in your blood. Because you
may have been recently exposed, I recommend another test in
4-12 weeks. When is a good time to come back in?”
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PLASMA HIV RNA:
POSITIVE
What it Means
A high viral load has been detected. In combination with a
negative or indeterminate HIV antibody test (e.g. Rapid
or ELISA), the positive test is indicative of acute (recent)
HIV infection.
Next Steps
Diagnose acute HIV infection
Inform patient of results in person in a private area
Help connect to treatment/ offer treatment for all non-pregnant patients
Follow up with HIV antibody tests at 3 and 6 months
For pregnant patients:
Connect with HIV provider
Start combination ART treatment as soon as possible
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