Of the 1.2 million Americans estimated to be living with HIV in the United States, approximately 250,000 are unaware of their diagnosis and therefore unable to access clinical care and life-sustaining treatment. The revised 2006 US Centers for Disease Control and Prevention's guidelines for HIV testing recommend universal, routine, and voluntary HIV screening in public and private health care settings for all adults and adolescents between 13 and 64 years old. These major revisions present new challenges for health care providers, hospitals, government agencies, and community advocacy groups. In this review, we discuss the important issues in diverse care venues such as opt-out testing, consent and confidentiality, barriers to treatment, and financial impact. The implications of the revised recommendations for HIV testing are addressed in the context of a fragmented, overstressed, underfunded US health care system.