Recommendations for HIV Screening of Gay, Bisexual, and Other Men …
Systematic Review
A CDC work group of federal employees comprising a diverse group of epidemiologists, clinicians, behavioral scientists, health policy experts, and health economists was convened. To identify studies comparing annual versus more frequent screening among MSM, the CDC work group conducted a systematic literature review, using methods adapted from the Guide for Community Preventive Services (7,8), and convened four consultations with 24 external experts to obtain their individual input on the programmatic and scientific evidence. During 2013–2014, and updated in January 2015, the CDC work group conducted a systematic review of published studies indexed in MEDLINE, EMBASE, PsycINFO, and CINAHL. The search was restricted to articles that 1) were published during 2005–2014 (last search conducted in January 2015); 2) described analyses conducted in the United States, Canada, Australia, New Zealand, and Western Europe; and 3) contained the following search terms: HIV seropositivity, HIV infection, AIDS serodiagnosis, sexually transmitted diseases/infections, men who have sex with men (MSM), high risk, test, screen. Included articles provided information on one of four outcomes of interest: 1) health benefits to individual MSM being screened or to the community (e.g., averted secondary HIV infections); 2) harms to individual MSM (stigma or out-of-pocket costs); 3) acceptability (MSM attitudes toward more frequent screening); or 4) feasibility (barriers to or facilitators of state or local screening). Included studies were restricted to those conducted in clinical settings. A manual search of gray literature was also conducted.
The CDC work group reviewed 6,479 abstracts resulting from the automated search, 111 of which met the initial screening inclusion criteria and were reviewed in full. Three members of the CDC work group, working in overlapping pairs, applied inclusion criteria to these studies, rating each study for outcome (benefits, harms, acceptability, or feasibility). They used a quantitative study assessment tool to note key findings. Discrepancies were resolved by a third reviewer who was not a member of the original pair (7,8).
Thirteen studies met the inclusion criteria and were evaluated on quality of evidence (9). For each of the four study outcomes, CDC HIV testing experts then evaluated the quality of evidence to determine design suitability (high, moderate, or low), execution (good, fair, or poor), and consistency of study results, with one exception: the eight mathematical modeling studies were not rated on quality of execution because of the lack of a grading system appropriate for the different mathematical model types included.
Overall, the quality of studies was low. Eleven studies addressed health or economic benefits of more frequent screening compared with annual screening. Eight of these were mathematical models that the CDC work group classified as having low suitability because of uncertainty about the validity of the parameter estimates and questions about the models’ generalizability. Two studies addressed intervals between HIV screening or diagnostic tests in clinical settings, but did not directly address the acceptability of more frequent than annual HIV screening among asymptomatic MSM. No studies addressed harms associated with, or the feasibility of, conducting more frequent HIV screening in clinical settings in the United States. Additional details about these studies can be found elsewhere (9).
After deliberations that involved discussion, consensus building, and voting, the CDC work group concluded that insufficient evidence exists in the published and unpublished literature to warrant changing CDC’s current recommendation to offer HIV screening at least annually to all sexually active MSM.
