HIV infection screening in France - Screening Strategies
These public health guidelines had two main objectives :
- to assess the relevance of modifying the methods for HIV infection screening and laboratory algorithms and to establish the role of RST
- to assess the possible changes in screening strategies
These conclusions comprise the second part of the public health guidelines on screening for HIV infection drafted by the Haute Autorité de Santé at the request of the General Directorate of Health. They concern the HIV screening system and strategies. The first section, published in October 2008, discussed the question of the procedures for performing screening tests for HIV infection.
Within the scope of this second focus of evaluation on the relevance of a change in the HIV screening system and strategies, several questions were upheld after an analysis of current challenges in screening and a clarification of the expectations of the DGS in relation to InVS, Afssaps and the CNS:
- Is it possible to identify sub-groups at risk to which screening must periodically be proposed? How often? In what structures?
- Should a screening test be proposed more systematically outside traditional risk-based screening? When? In what structures?
- Should counselling practices be changed in particular for pretest counselling?
Because of the persistence of late testing of HIV infection in particular by specific population groups that do not consider themselves to be “at risk”, and because the epidemic still affects population groups and regions in particular, the HAS recommends a two-part screening strategy:
- The objective of the first part is to improve early detection and to reduce late screening for HIV infection. It consists in proposing HIV screening to the whole population aged from 15 to 70 years including subjects with no particular characteristics and not exposed to any specific risk. It is based on the active mobilisation of general practitioners and other health providers. The results and impact of this strategy on the reduction in the number of late testers must be assessed after a first 5-year period. This guideline also aims to modify society’s image of HIV screening by promoting the idea that an improvement in a population’s awareness of its HIV serostatus may provide major benefits both at individual and community level.
- The other part takes into account the heterogeneity of the epidemic of HIV infection in France and the persistence of population groups that are more specifically affected. It involves the proposal of periodical targeted HIV screening in populations (men who have sex with men (MSM), heterosexuals who have had more than one sexual partner during the last 12 months, injectable drug users (IDU), people originating from regions with a high prevalence, persons engaged in prostitution, persons whose sexual partners are HIV-seropositive) and in circumstances.
- Concerning French Guiana, the HAS underlines the particular epidemiological characteristics of HIV infection which place this department in a generalised epidemic situation, and insists on the need to implement voluntarist screening strategies based on the regular proposal of the screening test to the whole population.
In addition, the HAS considers that voluntary screening should be encouraged and facilitated. The practice of voluntary screening must therefore remain one of the cornerstones of the screening system based in particular on general practitioners and CDAG/CIDDIST. In this respect and on basis of the literature review and after discussions by the working group, several potential avenues of improvement were proposed concerning dedicated and non-dedicated systems.
Lastly, the HAS recommends that the general population screening proposal is accompanied by the provision of appropriate information in order to obtain informed consent and an assessment of a person's capacity to receive the test result. Outside this framework, appropriate counselling must be offered in the different settings of the screening offer.