According to the CDC, everyone between the ages of 13 and 64 should get tested for HIV at least once as part of routine health care. Patients with ongoing risk factors should be screened annually. The CDC recommends using an “opt-out” approach to remove the stigma associated with HIV testing and facilitate earlier diagnosis and treatment (CDC, 2024e).

Risk factors requiring more frequent screening include:

• A man who has had sex with another man.
• Having anal or vaginal sex with someone who has HIV.
• Having more than one sex partner since your last HIV test.
• Sharing needles, syringes, or other drug injection equipment (for example, cookers).
• Exchanging sex for drugs or money.
• Being diagnosed with or treated for another sexually transmitted infection, hepatitis, or tuberculosis (TB).
• Having sex with someone who has done anything listed above or who has an unknown sexual history.

Testing is the only way to know HIV status and data suggests that currently about 15% of people who are HIV positive do not even know they are infected. Knowing your status allows you to get treatment and protect yourself and others if you are infected, and if you are not infected, you can take actions to prevent HIV (CDC, 2024f). Most insurers will cover the cost of testing at least once (WA DOH, n.d.-a)

Some people do not find out that they are infected with HIV until they get sick or show symptoms and go to a clinic or hospital and get tested for HIV. Since most people don’t have symptoms for years, they do not find out their status until later in the disease progression. By the time they find out they are infected, they have missed opportunities to get treatment, take medicines to treat HIV, and live a long, healthy life. They have also missed the chance to avoid passing the infection on to others.

3.1 HIV Tests

HIV is detectable by reliable, inexpensive, acceptable screening tests. Since the first HIV antibody test became available in 1985, several types of tests have been developed and approved by the Food and Drug Administration (FDA). Testing is always a two-step process utilizing a screening test and a confirmatory test. When the screening test is reactive (positive), then the confirmatory test is done.

There are three types of HIV tests available:

• Nucleic acid tests (NATs) detect HIV ribonucleic acid (RNA).
• Antigen/antibody combination tests detect HIV p24 antigen as well as HIV immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies.
• Antibody tests detect HIV IgM and/or IgG antibodies.

Note: The Western blot test is no longer used for HIV.

An HIV self-test is also available. It is done entirely at home or in a private location and can produce results within 20 minutes. Rapid self-test kits can be purchased at a pharmacy or online. The only rapid self-test currently available in the United States is an oral fluid test. To learn more, visit the OraQuick website. Visit gettested.cdc.gov to see if any organizations in your area are offering free or reduced cost self-tests.

Today's diagnostic tests reduce the time to diagnosis and treatment of early HIV infection by decreasing the window period. Following an exposure that leads to HIV infection, the time during which no diagnostic test can detect HIV is called the eclipse period. In contrast, the window periodis the time between a potential HIV exposure and an accurate test result. Each type of test has its own eclipse and window periods with nucleic acid tests (NAT) capable of detecting HIV the earliest (CDC, 2024e).

The window period for HIV tests can vary from 10 days to 12 weeks depending on the type of test and other factors. During the window period a person is infectious, with a high viral load, but still presents with a negative HIV test. This false negative test means the infected person might get a negative test result while actually having HIV. The point when an HIV antibody test becomes positive is called seroconversion.

3.1.1 Types of Tests

HIV tests are typically performed on blood or oral fluid. They may also be performed on urine. Which one is best will depend on patient details.

Antibody Test

An antibody test looks for antibodies to HIV in your blood or oral fluid.

• Most rapid tests and the only HIV self-test approved by the U.S. Food and Drug Administration (FDA) are antibody tests.
• In general, antibody tests that use blood from a vein can detect HIV sooner than tests done with blood from a finger stick or with oral fluid.

Antigen/Antibody Test

An antigen/antibody test looks for both HIV antibodies and antigens.

• Antigen/antibody tests are recommended for testing done in labs and are common in the United States. This lab test involves drawing blood from a vein.
• There is also a rapid antigen/antibody test available that is done with blood from a finger stick.

Nucleic Acid Test (NAT)

A NAT looks for the actual virus in the blood.

• With a NAT, a health care provider draws blood and sends it to a lab for testing.
• This test can tell if a person has HIV or how much virus is present in the blood (HIV viral load test).
• A NAT can detect HIV sooner than other types of tests.
• This test should be considered for people who have had a recent exposure or a possible exposure and have early symptoms of HIV and who have tested negative with an antibody or antigen/antibody test (CDC, 2024h).

3.1.2 Test Results

Negative Results

A negative result doesn’t necessarily mean that a person does not have HIV. That’s because of the window period—the time between HIV exposure and when a test can detect HIV in the body.

• If a person gets an HIV test after a potential HIV exposure and the result is negative, they should get tested again after the window period for the test they took.
• If a person tests again after the window period, has no possible HIV exposure during that time, and the result is negative, they do not have HIV.

A person who is sexually active or using needles to inject drugs should continue to take appropriate actions to prevent HIV. This may include taking medicines to prevent HIV.

A person with risk factors (noted above) should continue getting tested at least once a year.

Positive Results

If a person uses any type of antibody test and has a positive result, they will need a follow-up test to confirm the results.

• A person who takes a test in a community program or an HIV self-test and it’s positive should go to a health care provider for follow-up testing.
• If a person takes a test in a health care setting or a lab and it’s positive, the lab will conduct the follow-up testing, usually on the same blood sample as the first test.

• If the follow-up test is also positive, it means the person has HIV.

False-Positive Results

False-Positive Results and Specificity

When a person is not infected with HIV but receives a positive test result, that result is considered a false positive. Generally, HIV tests have high specificity, meaning that there are few false-positive results and most uninfected individuals are classified as uninfected by the test. If 1,000 uninfected people are tested with an HIV test and 4 have false-positive results, the HIV test’s specificity is 99.6% (996 true negative test results/1,000 HIV uninfected persons tested).

Causes of False-Positive HIV Test Results

False-positive test results can occur due to technical issues associated with the test or biological causes. Technical issues include specimen mix-up, mislabeling, improper handling, and misinterpretation of a visually read rapid test result. Biological causes include participation in an HIV vaccine study, autoimmune disorders and other medical conditions.

Additional Testing to Distinguish True Positive from False Positive

When a screening test is positive, additional testing is needed to determine if the positive result was accurate or whether the screening test result was falsely positive. If the screening test was a laboratory test, additional testing will generally occur using the original specimen. If it was a rapid test, additional testing may occur in one of three ways: by submitting a specimen to the laboratory, by conducting a rapid test algorithm (i.e., rapid tests from different test manufacturers in sequence), or by referring the individual to a healthcare provider who can conduct additional testing. If a rapid test algorithm is conducted and the initial test is reactive, but the subsequent test is not, additional testing in a laboratory is needed to rule out an early infection (CDC, 2018).

3.2 Getting Tested for HIV

3.2.1 Who Should Be Tested?

As noted above, according to the CDC, everyone between the ages of 13 and 64 should get tested for HIV at least once as part of routine health care. Patients with ongoing risk factors should be screened annually. For occupational exposure, refer to your employer’s protocol.

3.2.2 Where to Test for HIV

In Washington State most health care providers and clinics provide HIV testing and counseling, and many organizations offer these for free or at reduced cost for eligible persons. Call the Washington State HIV/AIDS hotline at 800 272 2437 (800 272 AIDS) for a referral to a public health, family planning, or community clinic in your county. As discussed above, self-tests can be purchased at a pharmacy or online.

3.2.3 Confidential Testing

With confidential HIV testing, clients give their real name, and the information about their testing is maintained in medical records. Their results are confidential. Results and testing information are not released to others except when medically necessary or under special circumstances such as when they sign a release for the results to be given to another person or agency. HIV is a reportable condition; therefore, confidential HIV results are reported to local public health officials.

3.2.4 Anonymous Testing

An anonymous HIV antibody test means that clients don’t give their name and the person who orders or performs the test does not maintain a record of the name of the person they are testing. If you want to know where to get tested anonymously, call the local health department for information about anonymous testing in your area.

3.2.5 Informed Consent Required

HIV testing can only be done with the person’s consent. Consent may be contained within a comprehensive consent for medical treatment. It can be verbal or written but must be specific to HIV and must be documented. There are some rare exceptions where a person can be tested without their consent, including source testing relating to occupation exposures and legally mandated situations specified in state law.

3.2.6 Testing Information and Risk Assessment Required

Aside from the exceptions listed above, all people tested for HIV should be assessed for their risk of infection and unless previously tested and having declined information, be provided with appropriate information about the test, including, but not limited to:

• The benefits of learning their HIV status and the potential dangers of the disease
• How HIV is transmitted and way in which it can be prevented
• Meaning of HIV test results and the importance of obtaining the results
• As appropriate, the availability of anonymous testing and the differences between anonymous and confidential testing

3.2.7 Advantages of Early Testing for HIV Infection

New drug therapies for HIV infection can sustain an infected person’s health for long periods of time. Early detection allows people with HIV the option to receive medical treatment sooner, take better care of their immune system, and stay healthier longer. Additionally, early detection of HIV allows people to take precautions not to infect others.

3.3 Counseling with HIV Testing

The person who provides HIV test counseling to clients should direct the counseling toward increasing client’s understanding of their own risk of acquiring or transmitting HIV, motivating them to reduce their risk, and assisting them to build skills to reduce their risk.

3.3.1 Pre-Test Counseling

Pre-test counseling should be based on recommendations of the CDC’s 2006 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings (latest available). See also Human Immunodeficiency Virus (HIV) Infection: Screening (USPSTF, 2019).

Pre-test counseling should always:

• Assist the individual to set realistic behavior-change goals and establish strategies for reducing their risk of acquiring or transmitting HIV
• Provide appropriate risk reduction skills-building opportunities to support their behavior change goals
• Provide or refer for other appropriate prevention, support, or medical services

Washington State law (WAC 246-100-207 and -209) requires that HIV test counseling be offered to all clients who are at risk for HIV or who request counseling. At the same time, the law states that people who refuse counseling should not be denied an HIV test; however, clients can refuse counseling. Also, individuals conducting HIV tests do not have to provide the counseling themselves—they can refer the client to another person or agency for counseling.

3.3.2 Post-Test Counseling

Those who test HIV negative should be offered an individual counseling session at the time they receive their test results. For those clients who test HIV-positive, counseling can’t just be offered, it must be provided or referred and in addition to what is provided to HIV-negative clients, must also include:

• If confidentially tested, the information that HIV is a reportable condition
• Either the provision of partner notification support or referral to public health for these services
• Appropriate referrals for alcohol and drug and mental health counseling, medical evaluation, TB screening, and HIV prevention and other support services

3.3.3 Confidentiality

People who perform HIV counseling in public health departments or health districts must sign strict confidentiality agreements. These agreements regulate the personal information that may be revealed in counseling and testing sessions as well as test results. HIV test results are kept in locked files, with only a few appropriate staff members having access to them.

3.3.4 HIV Testing: Pregnancy

Healthcare providers caring for pregnant clients are required by Washington State law to ensure HIV counseling and testing for each pregnant woman who is seeking prenatal care. All pregnant women are to be offered an HIV test and should be tested unless they refuse the HIV test. Those who refuse HIV testing must sign a form saying that they “opt out” of the HIV test. HIV-infected women can reduce the chance of transmitting the virus to their children if they take AZT during pregnancy and delivery.

3.3.5 HIV Testing: Sexual Assault

Sexual assault is prevalent in the United States. In 2010 the CDC began annual collection of comprehensive data on sexual violence victimization, including rape, with the National Intimate Sexual Violence Survey (NISVS). The last reported year of data in 2016/2017 indicate that more than 33.5 million (1 in 4) women reported completed or attempted rape victimization at some point in their lifetime. In addition, nearly 4.5 million (1 in 9) men report reported completed or attempted rape victimization at some point in their lifetime. The rates of lifetime sexual violence victimization among all racial and ethnic minorities are often higher for both women and men (Basile et al, 2022). Unfortunately, a study found that rape is hugely underreported in the United States due to women not wanting to report the crime and official records undercounting to “create the illusion of success in fighting violent crime” (Yung, 2014). Subsequent studies including by the Department of Justice suggest that as much as 80% of rape/sexual violence incidents go unreported.

For the 12-month period preceding the 2016/2017 data collection, 2.9 million women reported rape victimization. Less than one percent (0.3 or 340,000) of men reported rape victimization during that one-year period (Basile et al, 2022).

Apart from the emotional and physical trauma that accompany sexual assault, many victims are concerned about HIV infection from the rapist.

Sexual Assault HIV Risks

According to CDC, the odds of HIV infection from a sexual assault in the United States are 2 in 1,000. While this is a low risk, the fear of HIV poses an additional emotional burden on people who have been victims of sexual assault.

HIV Testing

When assault victims are worried about HIV, testing can help their healing process. Almost all such HIV tests will be negative and thus provide emotional relief to the victim. The very few who do test HIV-positive will need that information both for obtaining healthcare and as evidence in possible criminal court cases.

Assault and the Window Period

The window period for HIV testing must be taken into account when testing after an assault. Recall that it takes from 10 days to 12 weeks after exposure for markers to show up in an HIV test. Any test conducted shortly after the assault reveals only the original status of the victim. An early test can, however, provide proof that the victim was HIV-negative at the time of the assault, which may be useful as evidence in a criminal case.

To verify that the victim was not infected by the assault, it is necessary to test again after the window period. If, following an earlier HIV-negative result, the second test is HIV-positive, it indicates that the victim was infected by the assault (assuming no other opportunity for infection occurred in the interim).

Other Testing

When counseling assault victims about the risk of HIV, remember that the risk of HIV is low but there other potentially higher risks to be addressed. The risk of other STDs and pregnancy are much higher than HIV. Victims of sexual assault should be tested for STDs and females given emergency contraception. The emergency contraception hotline number 1-800-NOT-2-LATE (800 668 2528) should be provided by telephone rape counselors or other health care professionals.

Most experts recommend that a sexual assault victim should go directly to the nearest hospital emergency room, without first changing their clothing, bathing, or showering. Trained staff in the emergency department will counsel the victim, and may also offer testing or referral for HIV, STDs, and pregnancy. It is common practice for the ED physician or Sexual Assault Nurse Examiner (SANE) nurse to take DNA samples of blood or semen from the vagina, rectum, and perineal and adjacent areas, which can be used as evidence against the attacker.

Unfortunately, many hospitals do not have a dedicated SANE nurse or adequate testing materials and if rape victims are referred to another hospital, the victim may decide to do without the invasive medical care and testing. Some EDs may refer sexual assault survivors to the local health jurisdiction for HIV testing.

Many people feel that the ED setting is a profoundly unpleasant one in which to question sexual assault victims regarding their sexual risks history. However, testing shortly after a sexual assault provides baseline information on their status for various STD infections. All testing to be used for baseline information and legal action should be done confidentially.

Assailant Testing

In Washington State, only the victims of convicted sexual offenders may learn the attacker’s HIV status. The victim needs to consider whether to start post exposure prophylaxis (PEP) independent of the source’s test result, because the time between the attack and the conviction will likely be longer than the no later than 72-hour time frame recommended for starting PEP.

3.3.6 Partner Notification

Partner notification is a voluntary service provided to HIV positive people and their sexual partners or injecting-drug-sharing partners. This service is provided using a variety of strategies to maintain the confidentiality of both the HIV-infected client and the partners.

HIV-infected people are counseled about the importance of their partners’ being notified of exposure to HIV and offered an HIV test. Clients can choose to notify their partners themselves or to have public health staff notify them. When public health staff notify partners, they notify them of their exposure, provide counseling and information, and offer HIV testing without revealing the partner who tested HIV positive.

Partner notification is a critical tool for those notified because it alerts them to the need for being tested. If they are uninfected, they can take steps to ensure they don’t become infected. If infected, they can take steps to care for their own health and to ensure that they do not pass the virus on to others.

3.3.7 Reporting Requirements

AIDS cases have been reportable to the CDC since 1984, when the existence of the syndrome that follows HIV infection was clearly established.

AIDS and symptomatic HIV infections have been reportable to the Washington State Department of Health (WDOH) since 1984 and 1993, respectively. HIV cases became reportable to the Washington State Department of Health in fall 1999.