Identifying Undiagnosed Human Immunodeficiency Virus

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Abstract
IN THE PAST 20 YEARS, acquired immunodeficiency syndrome (AIDS) in the United States has evolved from being virtually unknown to being a leading killer of young adults. Despite its initial onset in specific communities, the epidemic has since crossed all demographic and socioeconomic boundaries, and the number of patients at risk for contracting the human immunodeficiency virus (HIV) has expanded dramatically.1 Several studies estimate that one third of HIV-infected patients in the United States have not undergone testing.2 The Centers for Disease Control and Prevention (CDC) report that approximately 300 000 people in the United States are infected with HIV and are unaware of their HIV-seropositive status.2 Among those who undergo testing, most patients begin care late in the course of disease.3 In Boston, Mass, Samet et al4 noted that on initial presentation for HIV medical care, 69 (36.5%) of 189 patients had CD4 counts of less than 200 cells/µL. In San Francisco, Calif, 29% of patients had CD4 counts of less than 200 cells/µL at first presentation.5 A recent study of a national sample of HIV-infected persons receiving medical care in the United States found that 29% of patients already considered themselves sick at the time of HIV diagnosis.6 Patients continue to present with late disease, despite the 1993 CDC recommendations for routine, voluntary HIV testing in all hospitalized patients in high-prevalence areas.7,8 This time lag from infection to initial testing and treatment represents therapeutic opportunity lost and extended risk for HIV transmission to uninfected partners.9