STANDARDS OF CARE

Routine HIV Testing

New York State Law requires - at a minimum - a one-time offer of an HIV test to all patients age 13 or older receiving primary care services from a physician, physician assistant, nurse practitioner or licensed midwife.

HIV RISK CHANGES, TEST REGULARLY.

Provider Perspective

  • Establishes a habit of testing all sexually active patients
  • Normalizes HIV testing for both the provider and the patient
  • Streamlined HIV testing does not lengthen visit when ordered with other preventative screening
  • Early diagnosis is a clear benefit of routine testing and treatment options are now immediately available
  • Prevention options including condoms for all STDs and HIV PrEP and PEP can be discussed

Patient Perspective

  • Reduces the stigma related to disclosing risk
  • Patients are more comfortable with HIV testing when offered as routine care
  • Positively impacts provider-patient relationship
  • Can start a conversation about other sexual health questions

When should you order HIV testing?

ROUTINE SCREENING

Every 3-5 years

  • For all sexually active individuals

Every year

If the patient or their partner:

  • is sexually active and has had condomless anal or vaginal sex with a new partner since the patient's most recent HIV test
  • has had any new STI within the last 12 months

Every 3-6 months

If the patient or their partner:

  • is a man who has sex with men
  • injects drugs
  • exchanges sex for money, drugs or housing
  • has a sex partner living with HIV and whose viral load is unknown or not undetectable for 6 months or more

CLINICAL INDICATIONS

  • Whenever STI screening is done on any patient who is not known to be living with HIV
  • For pregnant women at the first prenatal visit and retest during the third trimester
  • Tuberculosis (TB) - TB infection or suspected TB
  • Suspected Acute HIV (AHI)- persistent flu-like symptoms starting within 4 weeks of potential HIV exposure

Testing Options

Serum or plasma-based HIV antigen/antibody (HIV Ag/Ab) combination tests conducted in a laboratory
are the most sensitive HIV screening tests. If phlebotomy is being performed, use a laboratory-based HIV 1/2 Ag/Ab
combination test. If phlebotomy is not possible and/or rapid result is beneficial, use a fingerstick to obtain whole blood for rapid testing.

POINT OF CARE (POC) RAPID TEST

NYSDOH does not recommend any specific POC HIV tests. The Alere Determine remains the only POC test that detects HIV Ag and Ab. Other current POC tests detect HIV 1/2 Ab only. All POC tests have high specificity and sensitivity when used with whole blood.

  • Due to reduced sensitivity and specificity, HIV tests using oral fluid are not recommended.
  • For patients taking PrEP orif acute HIV issuspected, laboratory-based HIV 1/2 Ag/Ab testing is recommended.

OFFICE-BASED HIV TESTING

  1. Perform a POC HIV rapid test according to the manufacturer’s instructions including processing time
  2. In the setting of one reactive rapid test, rapid initiation of ART (RIA) may be started according to RIAprotocol*
  3. A 2nd POC test of different technology/manufacturer may be done to increase confidence in same day RIA*
  4. Always confirm reactive POC tests with a laboratory based diagnostic HIV 1/2 Ag/Ab assay with reflex
    Baseline blood work and the HIV 1/2 Ag/Ab assay are drawn prior to the first dose of ART medication

Patients newly diagnosed with HIV should be offered rapid initiation of ART (RIA) according to RIAprotocol

CDC LABORATORY-BASED HIV DIAGNOSTIC ALGORITHM – what to order, how to interpret.

 Order an HIV 1/2 Ag/Ab combination assay **with reflex**

 Always include “with reflex” so if indicated, additional recommended tests are conducted on the same specimen

 The complete report may include up to 3 separate test results if testing laboratory reports each testseparately

 Review the algorithm reports to confirm that all reports are received, and no further testing isindicated

Patients newly diagnosed with HIV should be offered rapid initiation of ART (RIA) according to RIA protocol:

Step 1 HIV 1/2 Ag/Ab Screening Assay (serum or plasma sample)
• Nonreactive specimens on a serum- or plasma-based test require no furthertesting.
• Reactive specimens reflex to Step 2 for a supplemental antibody differentiation immunoassay.

Reflex Step 2 HIV-1/2 Ab Differentiation
• If HIV-1 and/or HIV-2 antibodies are detected, the test is considered HIV positive. No further testing isindicated.
• If antibodies are not detected or the result is indeterminate, an HIV-1 RNA test isthe next step.

Reflex Step 3 HIV-1 RNA Assay
• If HIV-1 RNA is detected, this result is consistent with acute or earlyHIV-1.
• If HIV-1 RNA is not detected and antibodies were not confirmed by the step 2 differentiation test, the interpretation is HIV
negative. Interpret results within the context of the patient's overall clinical presentation.
• If HIV-1 RNA is not detected and the Ab differentiation result is HIV indeterminate or HIV-2 indeterminate, an HIV2 RNA test may be needed. In NYS, call Wadsworth Laboratory at (518) 474-2163 forassistance.

ART Regimens

ART Regimens

For specific details on choosing a regimen, see the full NYSDOH HIV Guideline for ART

Regimens in the tables are listed alphabetically. *These recommendations were updated on January 2019.

Preferred ART Regimens

Alternative ART Regimens

Drug-Drug Interactions

When initiating ART at the time of diagnosis avoid regimens containing abacavir unless results of HLA B-5701 testing are known to be negative.