Questions about risk behaviors are the most direct way to gauge a patient’s risk of HIV infection. However, it is also important to be aware of diseases that are acquired through similar risk behaviors – the presence of any one of these diseases significantly increases a patient’s risk of testing positive for HIV infection.
Other Sexually Transmitted Disease
The diagnosis of any sexually transmitted disease markedly raises the likelihood of HIV infection.
Not all sexually transmitted diseases (STDs) require the passage of infected body fluids from person to person for disease transmission (e.g., herpes simplex, syphilis), and therefore not all patients with STDs engage in risk behaviors that increase the likelihood of acquiring HIV infection. However, multiple studies have consistently shown marked increases in HIV seroprevalence among patients seeking treatment for other STDs. Certain STDs (e.g., gonorrhea) may be more associated with HIV than others, but in general, approximately 5% to 10% of patients with other STDs are HIV-infected. Unfortunately, studies also show that one half to two thirds of patients presenting for STD care have never been tested for HIV. Any STD diagnosis must prompt a recommendation for HIV testing.
Hepatitis
Patients with acute or chronic hepatitis В or С infections should be tested for HIV infection.
Chronic liver disease has become a major cause of morbidity and mortality in HIV-infected patients. Hepatitis В infection can be acquired either through sexual transmission or through exposure to contaminated blood. Hepatitis С infection is predominantly spread through blood exposure, most often in the setting of shared needles during intravenous drug use. Since the modes of acquisition of these infections are also risk factors for HIV infection, all patients with chronic viral hepatitis and patients with acute hepatitis В should be tested for HIV.
Psychiatric Illness
The prevalence of HIV infection in patients with severe psychiatric illnesses, including non-injection substance abuse, may be as high as 5% to 8%.
One review of seroprevalence studies demonstrated an aggregate seroprevalence of 8.5% in samples from mentally ill patients in New York City, but a 5.6% seroprevalence in smaller cities in the eastern United States. A later statewide seroprevalence survey from North Carolina found that 1.6% of patients admitted to state mental hospitals were HIV-infected. While this last number is significantly lower than those from urban centers, it still represents a fourfold increased risk over the United States population as a whole. Furthermore, it is worth noting that many patients with severe mental illness are chronically cared for in settings where HIV testing should be readily available.
Non-injection substance abuse (e.g., alcoholism or inhalational or crack cocaine use) has consistently been found to be a risk factor for HIV infection, presumably through the effect of intoxication on a patient’s ability to make sound decisions regarding risk behaviors. Although injection drug use is probably a more significant risk factor, non-action substance abuse is much more prevalent and likely drives a large number of the new HIV infections each year. Patients with active or past non-injection substance abuse are at higher risk for HIV infection.
Pregnancy
All pregnant women should be tested for HIV infection.
Babies born to HIV-infected mothers have a 25% chance of acquiring the infection in the perinatal period if the mother is not treated. However, with the advent of highly active antiretroviral therapy, it is estimated that the risk of transmission can be lowered to less than 2%. Unfortunately, a recently released report from CDC shows that only about half of pregnant women had documented HIV tests. It is precisely the process of offering HIV testing only to those women in perceived risk groups that limits the scope of testing. Because the risk-to-benefit ratio of preventing perinatal transmission so strongly favors testing, all pregnant women should be strongly encouraged to be tested. One issue that prevents an appropriately counseled woman from accepting the test may relate to domestic violence, so inquiring about its presence should be a part of counseling in such situations. A more thorough discussion of issues pertaining to HIV testing of pregnant women can be found elsewhere.
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