Every adolescent should know that they are being tested for HIV. We allow them to tell us "Gee, I’d rather not be tested." We hear that, but we hear it pretty rarely. I would say that fewer than 5% of kids opt out of an HIV test when the test is presented to them.
Key to this approach to routine testing is not having to offer extensive pretest preparation or written informed consent. A total of 40 states and the District of Columbia allow for facilitated testing that doesn’t require written, informed consent. Unfortunately, this also means that there are still a handful of states that do require prior written consent. So pediatricians need to know their state law. More information on testing in specific jurisdictions is available from the National HIV/AIDS Clinicians Consultation Center. Clearly, if you are in a state that requires informed consent, it adds a level of complexity to the testing process.
So how often should you test an adolescent? The Centers for Disease Control and Prevention recommends HIV testing for individuals of 13-64 years of age with some regularity and periodicity. There is some argument regarding the frequency of testing. If the pediatrician knows – either through questioning or even through suspicion – that the adolescent may be engaging in behaviors that might put her or him at risk of HIV infection, then that testing should be done annually. If you cannot ascertain an exact risk profile for an individual, decide what "reasonable periodicity" would be for you. My recommendation is to test at least every other year, and annually or more frequently in sexually active or drug-using adolescents.
Your patients and their families may ask you about HIV testing that is anonymous (that is, blinded testing in which no one except the patient knows who has been tested) vs. confidential (in which the identity of the patient tested is known to the tester). We prefer confidential testing because it allows us to link patients into care if and when they are identified as positive. For anonymous testing to work, you presume the adolescent is going to be mature enough to take action on the basis of a test result. That may be true, but the guidance of a thoughtful and compassionate health care provider to counsel an adolescent after a test result is invaluable.
Ideally, most pediatricians can perform rapid HIV testing. That is clearly the most efficient means because then patients have the results immediately. If you are not able to offer rapid testing and have to send blood out for a result, my feeling is that you should always communicate the results directly to an adolescent, as you would with any medical test. You can work out the best system of doing that for your practice. You could say something like, "Let me make sure I have your cell phone number so I have the best way to contact you. I would like to share your test results with you regardless of what they are."
If an initial blood test comes back positive, it can be anxiety provoking and clearly cause concerns on the part of the patient. Unfortunately, we cannot eliminate all of this anxiety. You can then contact the patient directly and say, "There is something about your testing we are going to need to repeat, so please make an appointment to come back in."
Dr. Lawrence D’Angelo is chief of the division of adolescent and young adult medicine at Children’s National Medical Center in Washington. He said he had no relevant financial disclosures.