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Patient education: Testing for HIV (Beyond the Basics)

Patient education: Testing for HIV (Beyond the Basics)
Author:
Paul E Sax, MD
Section Editor:
Martin S Hirsch, MD
Deputy Editor:
Jennifer Mitty, MD, MPH
Literature review current through: Aug 2023.
This topic last updated: Sep 09, 2020.

HIV TESTING OVERVIEW — Human immunodeficiency virus (HIV) testing is used to determine if you have HIV. Some individuals who are at the highest risk for HIV have not been tested, usually because they do not realize that they are at risk. Others avoid testing because they are worried about the possibility of a positive test result.

However, testing is encouraged because treatment for HIV is highly effective and early diagnosis can improve your chances of living longer and being healthier. Furthermore, knowing your HIV status can greatly reduce your risk of passing HIV to others if you take precautions.

WHAT IS HIV? — HIV is a virus that weakens your body's immune system, making it difficult to fight infections and certain cancers. People who have HIV may have no signs or symptoms of their illness, but they can still pass the infection to others through sexual contact or through exposure to contaminated needles. If HIV is not treated, you will eventually become very ill and may die. The advanced stage of HIV infection is called AIDS (acquired immune deficiency syndrome).

RISK FACTORS FOR HIV INFECTION — Nearly all HIV infections are acquired through sexual contact or exposure to contaminated needles.

You are at increased risk for getting HIV from sex if you:

Had a sexually transmitted disease

Had a sexual partner with HIV

Were a victim of sexual assault (see "Patient education: Care after sexual assault (Beyond the Basics)")

Are a man and had unprotected anal sex with another man

Had unprotected sex with multiple partners

Exchanged sex for money or drugs or have sex partners who do

You are at risk for exposure to HIV through contaminated needles if you have:

Injected drugs with shared needles or "works"

Been accidently stuck with a needle or sharp in a health care facility

Some people who have HIV have not been tested because they do not consider themselves at risk for infection.

Who should be tested for HIV — The Centers for Disease Control and Prevention (CDC) recommends that everyone between the ages of 13 and 64 years be tested for HIV at least once. There are two reasons for this recommendation:

The treatment of HIV is highly effective. People with HIV can live a nearly normal lifetime on available drugs. This treatment is most effective when it is started early in the course of the disease, before symptoms develop.

Treating HIV can help prevent spread of infection to others. If you know you have HIV, you can change your behavior so you are less likely to put other people at risk.

If you request the test from a health provider, it is important for him/her to know why since this information may influence test selection. For example, if the reason is a concern about a recent HIV exposure, the optimal test will be one that reveals early infection. Advantages of early detection include early treatment, which reduces symptoms of acute HIV infection (including fever, sore throat, and fatigue), reduction of the risk of HIV transmission to others, and reduction of the “HIV burden” stored in the body.

More frequent testing is required for individuals who are at high risk for infection. (See 'Risk factors for HIV infection' above and 'Frequency of testing' below.)

TYPES OF HIV TESTS — Several tests can be used to diagnose HIV infection. Most involve testing your blood. The preferred tests are antigen-antibody tests. Antigens are foreign substances in the body (eg, a viral protein) that cause a response from the immune system. Antibodies are the proteins that the body produces to counteract antigens.

Antibody-only tests — These tests detect the presence of antibodies that your body makes against HIV. If the antibody test is positive, the result is confirmed using another test. The second test determines whether the first test was accurate and, if so, whether the infection is from HIV-1 or HIV-2.

Combination antigen-antibody tests — These tests detect both the presence of virus (viral antigens) and the antibodies your body makes against the virus. The combination antigen-antibody tests are better able to identify early HIV infection compared with antibody-only tests. A positive test is followed by a second test to confirm the result.

Tests that measure HIV RNA — Certain tests detect HIV in your blood by measuring HIV RNA (a part of the virus). When the test measures the level of virus RNA in the blood, the result is referred to as the “viral load.” In most situations, viral load testing is not better than routine antibody or antigen-antibody testing. The exception is if you believe you acquired HIV very recently, in which case you should notify your provider so they can order a viral load test.

HIV TESTING METHODS — HIV testing can be performed in different ways (eg, rapid versus standard), and in different settings (eg, in a doctor’s office or clinic versus at home). All positive screening tests should be confirmed with another test.

Rapid tests — Rapid tests for HIV use blood from a finger prick or oral fluids. These tests provide results within 5 to 40 minutes and are useful because they do not require that you go back on another day for your results. A positive result must be confirmed with additional testing. A negative test does not have to be confirmed.

Standard tests — The standard HIV test uses a sample of blood taken from a vein. These tests are performed in a laboratory, and the results are usually available in a few days.

Anonymous testing — Anonymous testing allows you to be tested without disclosing your identity and is offered in some areas.

Home testing — Home test kits provide accurate and anonymous results and are available in most pharmacies. One type of test requires a small sample of blood, which is obtained by pricking the finger. The blood is blotted on a filter strip and mailed to a lab. The lab performs the test and calls you with the result. The results of the test are confidential and are not reported to anyone but you.

Another home-based test, called "OraQuick," uses oral fluids instead of blood. These are done at home. All positive test results should be confirmed by tests your health care provider can order. In addition, if you believe you acquired HIV very recently, the home tests are not as accurate, and you should have regular lab-based testing.

HIV TESTING PROCEDURE

Frequency of testing — The Centers for Disease Control and Prevention (CDC) recommend an HIV test for all people between age 13 and 64 and a repeat test if you have new risk factors, such as a new sexual partner who is known to be at risk for HIV. People who are at high risk for HIV, such as men who have sex with men, injection drug users, and those with multiple sex partners or a partner known to have HIV, should be tested every 6 to 12 months. (See 'Risk factors for HIV infection' above.)

If you think you were recently exposed to HIV and the initial test is negative or indeterminate, it should be repeated. A discussion of HIV testing in patients who were recently exposed to HIV is found below. (See 'Negative result' below and 'Indeterminate result' below.)

HIV TEST RESULTS — Test results are reported as being positive, negative, or indeterminate. The chances of having an inaccurate result are very small.

Negative result — If you have a negative blood test, you are unlikely to have HIV.

However, if you were exposed to HIV recently (ie, within a few weeks), you should be retested. Diagnosing recently acquired HIV infection is important; that is the time when a person is most likely to transmit HIV to someone else since virus levels are high. The frequency and duration of follow-up testing depend on the type of HIV test being used (see 'Types of HIV tests' above):

If an antibody-antigen test is negative, follow-up testing should be performed at six weeks and four months after the exposure. Your doctor may also wish to order a viral load test now.

If an antibody-only test is negative, repeat HIV testing should occur at six weeks, three months, and six months following the exposure since it can take up to six months for your body to make antibodies to the HIV virus.

Positive result — If your first HIV test is positive, the result needs to be confirmed with further tests. Most of the time, if your test was done in a doctor's office, the confirmatory testing will be done automatically. Sometimes an additional sample of blood will be required. Once you have any positive HIV test, it's important to follow up on all the results. Patients with untreated HIV infection can have serious complications and are at risk of transmitting infection to others.

Indeterminate result — An indeterminate result occurs when your result is not clearly positive or negative. The final result usually depends upon your risk of having HIV. In people at low risk for HIV infection, approximately 1 in 5000 results (0.02 percent) are indeterminate. Persons at high risk for HIV who have an indeterminate result may be in the early stages of HIV infection, and subsequent tests will be positive. Sometimes, a person who is healthy can have an indeterminate result for unknown reasons, and subsequent tests will be negative.

If you have an indeterminate result, you will need further testing, as determined by an HIV specialist; a viral load test may give an answer in just a couple of days (see 'Types of HIV tests' above). While awaiting the results of further testing, you should take precautions to avoid transmitting your potential infection to others. This includes discussing the possibility of infection with any sexual partners and use of a condom with every sexual encounter. You should also avoid sharing razors, toothbrushes, and any injection drug equipment (needles, syringes).

PREVENT HIV — In addition to testing, you should learn how to prevent HIV. This includes:

Encouraging your sexual partners to be tested for HIV

Using a latex or polyurethane condom with every sexual encounter

Avoiding drugs or alcohol that can affect your judgment about sexual activities

Avoiding activities such as sharing needles and syringes that have been used by other IV drug users

To help prevent infection after a possible exposure to HIV, your provider may prescribe antiviral medications (ie, medications used to treat HIV). If you had unprotected sex or shared needles with someone who has (or is at risk for) HIV, these medications may reduce your risk of getting HIV. However, you must contact your doctor or nurse right away so you can start the medications as early as possible, preferably within three days of being exposed to the virus. In addition, if you are at high risk for getting HIV (eg, if you are a man who has sex with men, or are an injection drug user), you can ask your provider about “pre-exposure prophylaxis,” which means you take antiviral medications before, and not just after each possible exposure.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: HIV/AIDS (The Basics)
Patient education: Preventing HIV after unprotected sex or needle-sharing (The Basics)
Patient education: Tests to monitor HIV (The Basics)
Patient education: Taking medicines to prevent HIV before exposure (The Basics)
Patient education: Blood or body fluid exposure (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Care after sexual assault (Beyond the Basics)
Patient education: Symptoms of HIV (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Professional Level Information:

Acute and early HIV infection: Treatment
Acute and early HIV infection: Pathogenesis and epidemiology
Initial evaluation of adults with HIV
Screening and diagnostic testing for HIV infection
Techniques and interpretation of HIV-1 RNA quantitation
Management of nonoccupational exposures to HIV and hepatitis B and C in adults

The following organizations also provide reliable health information.

Centers for Disease Control and Prevention (CDC)

Toll-free: (800) 311-3435

(www.cdc.gov and www.gettested.cdc.gov)

CDC (Centers for Disease Control and Prevention) National AIDS Hotline

Toll-free (English): (800) 342-2437

Toll-free (Spanish): (800) 344-7432

National Institute of Allergy and Infectious Diseases (NIAID)

(www.niaid.nih.gov)

HIV/AIDS Treatment Information Service

Toll-free: (800) 448-0440

(https://hivinfo.nih.gov/hiv-source/basic-hiv-and-aids-information)

AIDS Clinical Trials Information Service (ACTIS)

Toll-free: (800) 874-2572

(www.actis.org)

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  3. Chou R, Smits AK, Huffman LH, et al. Prenatal screening for HIV: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2005; 143:38.
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  7. US Preventive Services Task Force, Owens DK, Davidson KW, et al. Screening for HIV Infection: US Preventive Services Task Force Recommendation Statement. JAMA 2019; 321:2326.
  8. World Health Organization.Consolidated guidelines on HIV testing services. July 2015 http://apps.who.int/iris/bitstream/10665/179870/1/9789241508926_eng.pdf?ua=1&ua=1.
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