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An estimated 15% of patients living with HIV in the U.S. remain unaware of their status. HIV testing should be integrated across all levels of the healthcare system to facilitate early diagnosis. Approximately 40% of new HIV infections are transmitted by individuals living with undiagnosed HIV. Early detection reduces the risk of HIV-related complications and lowers the likelihood of transmission.[1][2] Who to Screen HIV testing should be considered during every clinical encounter, regardless of specialty, and all healthcare providers should be familiar with current screening recommendations.[3][4][5][6] Routine screening is recommended for all individuals aged 13 to 64 years in healthcare settings, without an upper age limit for those with ongoing risk factors. A 1-time test is sufficient for most individuals at low risk. However, certain populations require more frequent testing. These groups include men who have sex with men, particularly those aged 13 to 24 years, and individuals who inject drugs, exchange sex for money or food, engage in sexual activity with partners of unknown HIV status, and have partners who live with HIV, inject drugs, or are bisexual. Patients should be screened for HIV if they present with clinical signs or symptoms suggestive of HIV infection. Acute retroviral syndrome may occur 2 to 4 weeks after transmission and often presents as a constellation of nonspecific symptoms, such as fever, sore throat, and rash. Patients reporting possible HIV exposure should also be tested, regardless of symptomatology. These patients include individuals who request sexually transmitted infection testing, sustain occupational needle stick injuries or significant mucous membrane exposures, or have suspected or confirmed sexual or percutaneous exposures, such as needle sharing for substance use. In cases of possible HIV exposure, repeated testing is recommended during the 4- to 6-week period following exposure, with a final test at 12 weeks. Postexposure prophylaxis (PEP) should be considered for these patients and initiated as soon as possible, ideally within 24 hours and no later than 72 hours after exposure. The recommended PEP regimen includes a 2nd-generation integrase inhibitor in combination with tenofovir and either emtricitabine or lamivudine, administered for a total of 28 days.

In cases of possible HIV exposure, repeated testing is recommended during the 4- to 6-week period following exposure, with a final test at 12 weeks. Postexposure prophylaxis (PEP) should be considered for these patients and initiated as soon as possible, ideally within 24 hours and no later than 72 hours after exposure. The recommended PEP regimen includes a 2nd-generation integrase inhibitor in combination with tenofovir and either emtricitabine or lamivudine, administered for a total of 28 days. Patients initiating preexposure prophylaxis (PrEP) should undergo HIV testing within 7 days of starting therapy, and again every 2 to 6 months while receiving this treatment. HIV testing methods and frequency during PrEP vary with the route and agent used. See below for further discussion. Pregnant women should be screened for HIV early in pregnancy.[7] Early detection facilitates timely interventions to reduce the risk of perinatal transmission.

The healthcare system must integrate routine HIV screening across all care settings to identify undiagnosed HIV cases. Screening should not be confined to primary care or limited to traditionally high-risk populations, such as individuals residing in areas of high prevalence or receiving prenatal care. Instead, HIV testing should be normalized and extended to specialty practices, including dermatology, otolaryngology, and general surgery, particularly for patients who may not routinely engage with primary care. Emergency department-based screening is increasingly recognized as a critical component of HIV detection. Nontargeted HIV testing in this setting has demonstrated improved acceptance, particularly when the timing and method of test delivery align with the patient’s clinical workflow.[26] Combined HIV and hepatitis C virus screening strategies have also proven both effective and efficient in increasing case identification.[27]