The Guide to Clinical Preventive Services 2008 - part 5 ppt

Clinical Considerationsn A person is considered at increased risk for HIVinfection and thus should be offered HIV testing if he or she reports 1 or more individual risk factors or receiv

Screening for Hepatitis C in Adults

approximately 59% of all positive tests using thethird-generation EIA test with 97% specificitywould be false positive As a result, confirmatorytesting is recommended with the strip recombinantimmunoblot assay (third-generation RIBA)

n Important predictors of progressive HCV infectioninclude older age at acquisition; longer duration ofinfection; and presence of comorbid conditions,such as alcohol misuse, HIV infection, or otherchronic liver disease Asymptomatic individualswith HCV infection identified through screeningmay benefit from interventions designed to reduceliver injury from other causes, such as counseling toavoid alcohol misuse and immunization againsthepatitis A and hepatitis B However, there islimited evidence of the effectiveness of theseinterventions

This USPSTF recommendation was first published in:

Ann Intern Med 2004;140(6):462-464.

Clinical Considerations

n A person is considered at increased risk for HIVinfection (and thus should be offered HIV testing)

if he or she reports 1 or more individual risk factors

or receives health care in a prevalence or risk clinical setting

high-n Individual risk for HIV infection is assessed through

a careful patient history Those at increased risk (asdetermined by prevalence rates) include: men whohave had sex with men after 1975; men and womenhaving unprotected sex with multiple partners; past

or present injection drug users; men and womenwho exchange sex for money or drugs or have sexpartners who do; individuals whose past or presentsex partners were HIV-infected, bisexual, or

Screening for HIV

Summary of Recommendations

The U.S Preventive Services Task Force

(USPSTF) strongly recommends that cliniciansscreen for human immunodeficiency virus (HIV)all adolescents and adults at increased risk for HIV

infection Grade: A Recommendation.

The USPSTF makes no recommendation for oragainst routinely screening for HIV adolescentsand adults who are not at increased risk for HIV

infection Grade: C Recommendation.

The USPSTF recommends that clinicians screen

all pregnant women for HIV Grade: A

Recommendation.

Screening for HIV

injection drug users; persons being treated forsexually transmitted diseases (STDs); and personswith a history of blood transfusion between 1978and 1985 Persons who request an HIV test despitereporting no individual risk factors may also beconsidered at increased risk, since this group islikely to include individuals not willing to disclosehigh risk behaviors

n There is good evidence of increased yield fromroutine HIV screening of persons who report noindividual risk factors but are seen in high-risk orhigh-prevalence clinical settings High-risk settingsinclude STD clinics, correctional facilities, homelessshelters, tuberculosis clinics, clinics serving menwho have sex with men, and adolescent healthclinics with a high prevalence of STDs High-prevalence settings are defined by the Centers forDisease Control and Prevention (CDC) as thoseknown to have a 1% or greater prevalence ofinfection among the patient population beingserved Where possible, clinicians should considerthe prevalence of HIV infection or the risk

characteristics of the population they serve indetermining an appropriate screening strategy Dataare currently lacking to guide clinical decisionsabout the optimal frequency of HIV screening

n Current evidence supports the benefit of identifyingand treating asymptomatic individuals in

immunologically advanced stages of HIV disease(CD4 cell counts < 200 cells/mm3) with highly

prophylaxis and immunization against certainopportunistic infections have also been shown to beeffective interventions for these individuals Use ofHAART can be considered for asymptomaticindividuals who are in an earlier stage of disease but

at high risk for disease progression (CD4 cell count

< 350 cells/mm3 or viral load > 100,000

copies/mL), although definitive evidence of asignificant benefit of starting HAART at thesecounts is currently lacking

n The standard test for diagnosing HIV infection, therepeatedly reactive enzyme immunoassay followed

by confirmatory western blot or immunofluorescentassay, is highly accurate (sensitivity and specificity >99%) Rapid HIV antibody testing is also highlyaccurate; can be performed in 10 to 30 minutes;and, when offered at the point of care, is useful forscreening high risk patients who do not receiveregular medical care (e.g., those seen in emergencydepartments), as well as women with unknownHIV status who present in active labor

n Early identification of maternal HIV seropositivityallows early antiretroviral treatment to preventmother-to-child transmission, allows providers toavoid obstetric practices that may increase the riskfor transmission, and allows an opportunity tocounsel the mother against breastfeeding (alsoknown to increase the risk for transmission) There

is evidence that the adoption of “opt-out” strategies

to screen pregnant women (who are informed that

Screening for HIV

an HIV test will be conducted as a standard part ofprenatal care unless they decline it) has resulted inhigher testing rates However, ethical and legalconcerns of not obtaining specific informed consentfor an HIV test using the “opt-out” strategy havebeen raised While dramatic reductions in HIVtransmission to neonates have been noted as a result

of early prenatal detection and treatment, the extent

to which detection of HIV infection and

intervention during pregnancy may improve term maternal outcomes is unclear

long-This USPSTF recommendation was first published in:

Ann Intern Med 2005;143:32-37.

Screening for HIV

Clinical Considerations

n Populations at increased risk for syphilis infection(as determined by incident rates) include men whohave sex with men and engage in high-risk sexualbehavior, commercial sex workers, persons whoexchange sex for drugs, and those in adult

correctional facilities There is no evidence tosupport an optimal screening frequency in thispopulation Clinicians should consider the

characteristics of the communities they serve indetermining appropriate screening strategies.Prevalence of syphilis infection varies widely amongcommunities and patient populations For example,the prevalence of syphilis infection differs by region

Summary of Recommendations

The U.S Preventive Services Task Force

(USPSTF) strongly recommends that cliniciansscreen persons at increased risk for syphilis

infection Grade: A Recommendation.

The USPSTF strongly recommends that

clinicians screen all pregnant women for syphilis

infection Grade: A Recommendation.

The USPSTF recommends against routinescreening of asymptomatic persons who are not at

increased risk for syphilis infection Grade: D Recommendation.

Screening for Syphilis Infection

(the prevalence of infection is higher in the

southern U.S and in some metropolitan areas than

it is in the U.S as a whole) and by ethnicity (theprevalence of syphilis infection is higher in Hispanicand African American populations than it is in thewhite population)

n Persons diagnosed with other sexually transmitteddiseases (STDs) (i.e., chlamydia, gonorrhea, genitalherpes simplex, human papilloma virus, and HIV)may be more likely than others to engage in high-risk behavior, placing them at increased risk forsyphilis; however, there is no evidence that supportsthe routine screening of individuals diagnosed withother STDs for syphilis infection Clinicians shoulduse clinical judgment to individualize screening forsyphilis infection based on local prevalence andother risk factors (see above)

n Nontreponemal tests commonly used for initialscreening are the Venereal Disease Research

Laboratory (VDRL) or Rapid Plasma Reagin(RPR), followed by a confirmatory fluorescenttreponemal antibody absorbed (FTA-ABS) or T.pallidum particle agglutination (TP-PA) Theoptimal screening interval in average- and high-riskpersons has not been determined

n All pregnant women should be tested at their firstprenatal visit For women in high-risk groups,repeat serologic testing may be necessary in thethird trimester and at delivery Follow-up serologic

Cancer Screening for Syphilis Infection

tests should be obtained to document declineinitially after treatment These follow-up testsshould be performed using the same nontreponemaltest initially used to document infections (e.g.,VDRL or RPR) to ensure comparability

This USPSTF recommendation was first published in:

Ann Fam Med 2004;2(4):362-365.

Screening for Syphilis Infection

Clinical Considerations

n The USPSTF did not review the evidence for theeffectiveness of case-finding tools; however, allclinicians examining children and adults should bealert to physical and behavioral signs and symptomsassociated with abuse or neglect Patients in whomabuse is suspected should receive proper

documentation of the incident and physical

findings (e.g., photographs, body maps); treatmentfor physical injuries; arrangements for skilledcounseling by a mental health professional; and thetelephone numbers of local crisis centers, shelters,and protective service agencies

Injury and Violence

Screening for Family and Intimate

Partner Violence

Summary of Recommendation

The U.S Preventive Services Task Force

(USPSTF) found insufficient evidence to

recommend for or against routine screening ofparents or guardians for the physical abuse orneglect of children, of women for intimate partnerviolence, or of older adults or their caregivers for

elder abuse Grade: I Statement.

n Victims of family violence are primarily children,female spouses/intimate partners, and older adults.Numerous risk factors for family violence have beenidentified, although some may be confounded bysocioeconomic factors Factors associated with childabuse or neglect include low income status, lowmaternal education, non-white race, large familysize, young maternal age, single-parent household,parental psychiatric disturbances, and presence of astepfather Factors associated with intimate partnerviolence include young age, low income status,pregnancy, mental health problems, alcohol orsubstance use by victims or perpetrators, separated

or divorced status, and history of childhood sexualand/or physical abuse Factors associated with theabuse of older adults include increasing age, non-white race, low income status, functional

impairment, cognitive disability, substance use, pooremotional state, low self-esteem, cohabitation, andlack of social support

n Several instruments to screen parents for child abusehave been studied, but their ability to predict childabuse or neglect is limited Instruments to screenfor intimate partner violence have also been

developed, and although some have demonstratedgood internal consistency (e.g., the HITS [Hurt,Insulted, Threatened, Screamed at] instrument, thePartner Abuse Interview, and the Women’s

Experience with Battering [WEB] Scale), none havebeen validated against measurable outcomes Only afew screening instruments (the Caregiver Abuse

Cancer Screening for Family and Intimate Partner Violence

Screen [CASE] and the Hwalek-Sengstock ElderAbuse Screening Test [HSEAST]) have beendeveloped to identify potential older victims ofabuse or their abusive caretakers Both of these toolscorrelated well with previously validated

instruments when administered in the community,but have not been tested in the primary care clinicalsetting.1

n Home visit programs directed at high-risk mothers(identified on the basis of sociodemographic riskfactors) have improved developmental outcomesand decreased the incidence of child abuse andneglect, as well as decreased rates of maternalcriminal activity and drug use

Reference

1 Nelson HD, Nygren P, Qazi Y Screening for Family and

Intimate Partner Violence Systematic Evidence Review

No 28 (Prepared by the Oregon Health & ScienceUniversity Evidence-based Practice Center underContract No 290-97-0018) Rockville, MD: Agency forHealthcare Research and Quality February 2004.(Available on the AHRQ Web site at:

www.ahrq.gov/clinic/serfiles.htm)

This USPSTF recommendation was first published in:

Ann Intern Med 2004;140(5):382-386.

Cancer Screening for Family and Intimate Partner Violence

Clinical Considerations

n This recommendation refers to behavioral

counseling interventions performed in the primarycare setting, addressing parents of all infants andchildren, children, adolescents, and adults

n The injury prevention benefits of child safety seatand booster seat use require proper use (That is,

Counseling About Proper Use of Motor Vehicle Occupant Restraints and

Avoidance of Alcohol Use While Driving

Summary of Recommendations

The U.S Preventive Services Task Force

(USPSTF) concludes that the current evidence isinsufficient to assess the incremental benefit,

beyond the efficacy of legislation and based interventions, of counseling in the primarycare setting, in improving rates of proper use ofmotor vehicle occupant restraints (child safetyseats, booster seats, and lap-and-shoulder belts)

community-Grade: I Statement.

The USPSTF concludes that the current

evidence is insufficient to assess the balance ofbenefits and harms of routine counseling of allpatients in the primary care setting to reduce

driving while under the influence of alcohol orriding with drivers who are alcohol-impaired

Grade: I Statement.

the seats should be age- and weight-appropriate andshould be installed and placed into the vehiclecorrectly.) Infants younger than 1 year of age andweighing fewer than 20 pounds should be placed inrear-facing, infant-only car safety seats or

convertible seats positioned in the back seat Infantsyounger than 1 year of age and weighing between

20 and 35 pounds should be placed in rear-facingconvertible seats positioned in the back seat Rear-facing child safety seats must not be placed in thefront passenger seat of any vehicle that is equippedwith an airbag on the front passenger side Death orserious injury can result from the impact of theairbag against the child safety seat Toddlers 1 to 4years of age weighing 20 to 40 pounds should berestrained in a forward-facing convertible seat orforward-facing-only seat positioned in the back seat.Young children 4 to 8 years of age and up to 4’9”(57 inches) in height should be placed in a boosterseat in the back seat After this age (or height), lap-and-should belt use is appropriate Children

younger than 13 years of age should sit in the backseat with lap-and-shoulder belts

n Behavioral counseling interventions that include aneducational component, as well as a demonstration

of use or a distribution component, are moreeffective than those that include education alone

n Clinical counseling in conjunction with

community-based interventions has been effective

in increasing proper use of child safety seats Over

Avoidance of Alcohol Use While Driving

Avoidance of Alcohol Use While Driving

the past decade, legislation and enforcement havecontributed substantially to the increasing trends inchild safety seat and seat belt use A comprehensivestrategy that includes community-based

interventions, primary care counseling in theprimary care setting, legislation, and enforcement iscritical to the improvement of proper safety

restraint use and decrease in the incidence ofMVOI

This USPSTF recommendation was first published in:

Ann Intern Med 2007;147:187-93.