Domestic Refugee Health Screening Guidance
HIV Screening
Last updated: July 2022
On this page:
Minnesota HIV screening recommendations
Microlearning series: HIV
Labs
Best practices
Background and epidemiology
Resources
HIV prevention resources
Screening for HIV in infants and children
References
Minnesota HIV screening recommendations
- Screen all refugees 13-64 years of age for HIV.
- Screening of all refugees on arrival, including those 12 years and younger or 65 years and older, is also encouraged. Children 12 years and younger should be screened unless mother has negative HIV status and child is otherwise at low risk. In most situations, complete risk factor info is unavailable, and child should be screened.
- All pregnant refugees should undergo HIV screening as part of post-arrival and prenatal medical screening and care.
- Repeat screening three to six months following resettlement is recommended for refugees with a recent exposure or high-risk activity to identify individuals who may be in the “window period” when they arrive in the United States. Subsequent screening should be done in accordance with CDC guidelines.
- Cases of HIV, including AIDS, must be reported to the Minnesota Department of Health (MDH) HIV Surveillance Unit within one working day of diagnosis. This includes people who may have a prior diagnosis of HIV before arrival and are confirmed to be living with HIV based on lab work in Minnesota. Reporting information and forms can be found at Reporting Human Immunodeficiency Virus (HIV), Including Acquired Immunodeficiency Syndrome (AIDS). In addition, Minnesota law requires the reporting of pregnancy in a person living with HIV, including AIDS, to MDH within one working day of knowledge of the pregnancy, using the Perinatal HIV Report form.
Microlearning series: HIV
This video (under 5 minutes) is meant to serve as a summary of HIV screening guidance and resources for providers completing the refugee health screening and all those serving new arrivals.
Refugee Health Microlearning Series: HIV Transcript (PDF)
Labs
- CDC recommends the use of laboratory HIV antibody/antigen (ab/ag) tests that detect HIV-1 and HIV-2 antibodies and p24 antigen for screening children over 24 months old and adults. These tests detect HIV sooner than tests detecting HIV antibodies only. Specimens with a reactive antigen/antibody immunoassay result should be tested with an FDA-approved supplemental antibody immunoassay that differentiates HIV-1 antibodies from HIV-2 antibodies. Specimens that are reactive on the initial antigen/antibody immunoassay and non-reactive or indeterminate on the HIV-1/HIV-2 antibody differentiation immunoassay should be tested with an FDA-approved HIV-1 nucleic acid test (NAT). Please refer to 2018 Quick reference guide: Recommended laboratory HIV testing algorithm for serum or plasma specimens for further information on recommended laboratory HIV testing and the interpretation of HIV test results.
- If positive for HIV antibodies, ensure specific HIV-2 testing for those native to or transited through Angola, Benin, Burkina Faso, Cape Verde, Ivory Coast, Gambia, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Mozambique, Niger, Sao Tome, Senegal, Sierra Leone, and Togo.
- HIV RNA or HIV DNA nucleic acid tests (NATs) that directly detect HIV must be used to diagnose HIV in infants and children less than 24 months old. HIV antibody/antigen tests should not be used for this age group.
Best practices
- Screening should be performed on all refugees unless they decline. Refugees should be clearly informed orally or in writing that HIV testing will be performed. Oral or written information should include an explanation of HIV and the meanings of positive and negative test results, and the patient should be offered an opportunity to ask questions. With such notification, consent for HIV screening should be incorporated into the patient’s general informed consent for medical care on the same basis as other screening or diagnostic tests, taking care to address it in a non-stigmatizing manner.
- For all people confirmed to be living with HIV, care, patient education, treatment, and preventative services should be ensured:
- Care should be culturally sensitive. Efforts should be made to understand the context of HIV testing, diagnosis, and care within specific cultural and societal norms.
- Language access should be a priority. Information about HIV and HIV testing should be provided in the languages of the commonly encountered populations within the service area. The competence of interpreters and bilingual staff to provide language assistance to patients with limited English proficiency must be ensured.
- Treatment efficacy, including U=U, should be clearly communicated.
Background and epidemiology
In 2020, more than 37 million people were living with HIV at the end of 2020, with approximately 680,000 deaths due to AIDS, and an estimated 1.5 million new HIV infections. While HIV/AIDS affects individuals throughout the world, over two thirds (25.4 million) of people infected with HIV reside in Africa (World Health Organization: HIV/AIDS Fact Sheet).
Prior to departure to the United States, all refugees undergo a pre-departure medical screening process. This process generally includes screening for inadmissible medical conditions (e.g., active tuberculosis), as well as presumptive pre-departure treatment for malaria and intestinal parasites, when appropriate. In 2010, HIV was removed from the list of inadmissible conditions, and refugees are no longer routinely tested for HIV prior to departure to the United States.
Identifying HIV has implications for the individual refugee, the clinical provider, and the public health system. Early entry into care and treatment for HIV has been associated with improved survival. The use of highly active antiretroviral therapy (HAART) has led to substantial declines in morbidity and mortality experienced by people living with HIV. In addition, knowing one’s HIV status has important implications for the prevention of transmission to others.
Recent developments in HIV treatment and prevention are important to introduce to any patient living with HIV. This includes the concept that Undetectable = Untransmittable. This prevention method is estimated to be 100% effective for preventing sexual transmission if the person living with HIV takes their medication as prescribed and gets and stays undetectable.1 Sharing this information may improve the social and emotional wellbeing of people living with HIV, help motivate treatment uptake, medication adherence, and engagement in care, and reduce anxiety associated with HIV testing.2
Since 2015, the number of HIV/AIDS cases diagnosed has remained relatively stable with an average of almost 300 cases diagnosed in Minnesota each year. In 2020, there were 226 new HIV diagnoses. By the end of 2020, an estimated 9,422 people with HIV/AIDS were assumed to be living in Minnesota. Current data for Minnesota is available at HIV Statistics.
Among refugee arrivals to Minnesota from 2010-2019 who received a post-arrival Refugee Health Assessment (RHA), 17,853 (94%) were tested for HIV. Less than 1% tested positive for HIV. Among those who did test positive, 64% were known HIV+ prior to U.S. arrival and 38% were new HIV diagnoses. Of the 73 refugees who tested positive for HIV during this time, 63 (86%) were from sub-Saharan Africa. All individuals living with HIV (both those known overseas and new diagnoses) are reported to MDH HIV Surveillance for further follow-up.
Prevalence of HIV among Primary Refugees to Minnesota, 2010-2019
| Region of Origin* | Received RHA** | Screened for HIV (%)*** | Total HIV+ (%)**** | HIV+ Status Known Overseas (%)† | New HIV+ Diagnosis (%)† |
|---|---|---|---|---|---|
| East Asia/Pacific | 26 | 24 (92%) | 0 (0%) | N/A | N/A |
| Eastern Europe | 652 | 561 (86%) | 0 (0%) | N/A | N/A |
| Latin America/Caribbean | 223 | 210 (94%) | 2 (1%) | 0 (0%) | 2 (100%) |
| North Africa/Middle East | 1,255 | 1,142 (91%) | 0 (0%) | N/A | N/A |
| South/Southeast Asia | 7,979 | 7,624 (96%) | 8 (<1%) | 6 (75%) | 2 (25%) |
| Sub-Saharan Africa | 8,762 | 8,292 (95%) | 63 (1%) | 41 (65%) | 22 (35%) |
| Total | 18,897 | 17,853 (94%) | 73 (<1%) | 47 (64%) | 26 (36%) |
*Based on MDH's world regions
**Refugee Health Assessment (RHA): health screening done in U.S., usually within 90 days of U.S. arrival
***% among those who received RHA
****% among those screened for HIV
† % among those who tested positive for HIV at RHA
Resources
- HIV/AIDS
MDH HIV/AIDS information on prevention and care, statistics, and more. - Reporting Human Immunodeficiency Virus (HIV), Including Acquired Immunodeficiency Syndrome (AIDS)
- Perinatal HIV Transmission for Providers
- STD/HIV Partner Services Program
MDH Partner and Care Link Services is a free, time-limited, and confidential program that provides the following services to all Minnesotans living with HIV:- Help with sensitive and private partner notification.
- Proactively help newly diagnosed people to start and stay in HIV care.
- Re-engage people living with HIV who are not currently receiving HIV care, including people newly arriving to the United States.
- Provide referrals for supportive services to address barriers to care.
- Health care providers can make a referral to MDH Partner and Care Link Services by calling a Health Representative at 651-201-5414.
HIV prevention resources
Pre-Exposure Prophylaxis (PrEP) is a once-daily antiretroviral medication for people who are HIV negative. PrEP is used to prevent HIV transmitted through sexual contact and injection drug use. PrEP could be right for you if you are HIV negative and:
- Your sexual partner is living with HIV
- You have recently had a bacterial STD like gonorrhea, chlamydia, or syphilis
- You don't always use condoms when you have anal and/or vaginal sex
- You exchange sex for money, shelter or other goods
- You share syringes or other injection equipment
- You have recently participated in a drug treatment program
- You live in an area or network with a high rate of HIV infection
MDH provides funding to several local agencies to provide PrEP navigation services. All services are free and confidential. For more information about helping people access PrEP in Minnesota, please visit Pre-Exposure Prophylaxis (PrEP). Provide the MDH Pre-Exposure Prophylaxis (PrEP) (PDF) fact sheet to people requesting more information about PrEP.
Children’s Minnesota Perinatal and Pediatric HIV Program provides care and prevention services to women, children, youth, and their families living with HIV across the state of Minnesota. In addition, clinicians are available for provider-to-provider consultations through Children’s Minnesota Perinatal and Pediatric HIV Program.
- For information about pregnancy and HIV, clinical support, technical assistance, or perinatal referrals, call the Perinatal HIV Nurse Coordinator at 612-387-2989.
- For emergencies or after-hours clinical consultation, call the Minnesota Physician Access Line at 612-343-2121. Ask for the on-call Infectious Disease physician.
- For general program information, pediatric referrals, and training requests, call the Perinatal and Pediatric HIV Program Coordinator at 651-226-8211.
The Minnesota AIDSLine is Minnesota’s statewide information and referral service that can answer questions about HIV and link individuals to care and supportive services.
- Website: Minnesota AIDSline
- Phone: 612-373-2437
- Email: aidsline@rainbowhealth.org
- Text: AIDSLine to 839863
The National Clinician Consultation Center provides expert advice to health providers on a variety of HIV-related topics, including treatment and prevention. Information on initiating a phone consultation can be found at National Clinician Consultation Center.
Screening for HIV in infants and children
Antigen-antibody combination immunoassays are not recommended for the diagnosis of HIV in infants and children younger than 24 months old because they are less sensitive than an HIV NAT and HIV-exposed children may have residual maternal HIV antibodies; therefore, a virologic test (DNA or RNA PCR) must be used. A positive HIV test should be confirmed as soon as possible by repeat virologic testing, because false-positive results can occur with both RNA and DNA assays. In addition, if the infant has had a known prenatal or postnatal exposure (including breastfeeding), repeat virologic testing may be needed to exclude HIV depending on the age of the infant and timing of the exposure. Consultation with a pediatric infectious disease specialist is recommended for any infant/child with a known HIV exposure. Please refer to NIH: Diagnosis of HIV Infection in Infants and Children or consult with Children’s Minnesota Perinatal and Pediatric HIV program for further diagnostic testing or clinical case management information.
References
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. Effectiveness of Prevention Strategies to Reduce the Risk of Acquiring or Transmitting HIV. Accessed September 10, 2021.
- Beyrer C, Adaora AA, Hodder SL, et al. Call to action: how can the US Ending the HIV Epidemic initiative succeed? The Lancet. 2021: 397(10279); 1151-1156. Accessed September 10, 2021.