Updating the HIV-testing guidelines--a modest change with major consequences.

n engl j med 368;10 nejm.org march 7, 2013 884 cludes with high certainty that early detection and treatment of HIV . . . would result in substantial public health benefit [and that] earlier initiation of ART in HIV positive persons . . . could substantially reduce disease burden” — there could have been no public surprise. The same month, the Pacific Northwest Evidencebased Practice Center’s unambiguous review of the evidence favoring routine HIV screening had been published.5 The debate over HIV screening has extended over 25 years, driven initially by concerns about discrimination and the appropriate rigor of consent procedures. More recently, controversy has centered on the scope of screening efforts — whether they should be targeted at the groups at highest risk or should be a routine element of clinical practice. With the USPSTF recommendations, the curtain will at last come down on that debate. What remains to be seen is whether routine screening provided at no cost to patients will substantially alter the persistent inability to identify 20 to 25% of Americans with HIV infection. Failure will have measurable clinical consequences for those who enter care too late and public health consequences for the imperative to reduce HIV transmission in populations.