May 21, 2006

Caplan & McGee: HIV Testing Must Be the Routine

In today's Times-Union we argue that the CDC guidelines recommending that physicians offer HIV testing to all patients does not go far enough:
Centers for Disease Control and Prevention in Atlanta has let it be known that it is going to change its guidelines regarding testing Americans for HIV. It is going to recommend that doctors offer HIV testing to all of their patients as part of routine medical care. The change is long overdue. In fact, it does not go far enough.

The change toward routine testing for HIV -- the human immunodeficiency virus that causes AIDS -- is raising some ethical eyebrows. Some are worried that the government will know exactly who is HIV positive. This fear is understandable, given the current administration's obsession with snooping on all of us without warrants and its well-known antipathy toward homosexuals, as evidenced by its use of anti-gay rhetoric as a wedge issue in the 2004 presidential campaign against John Kerry.

Others fret that busy doctors will harass poor patients into consenting to testing. As Catherine Christeller of the Chicago Women's AIDS Project told The Wall Street Journal, "Women -- particularly minority women -- have a concern about abuses." What starts as an offer might quickly become an expectation.

And still others worry that when you have routine testing offered, it may not be long before your boss knows the results. At companies that run their own health clinics, the promise of privacy is not especially credible.

Testing for HIV has provoked worries like these for more than two decades. That is why there has been no required or routine testing for HIV except in a few states, such as New York, which test newborn babies.

HIV testing has certainly been encouraged for people in high risk groups -- gay men, those who utilize intravenous drugs and heterosexuals who have multiple sexual partners or sex with people who do such as prostitutes -- but encouragement is all there has been.

In some states, including New York, a special informed consent form must be used before testing for HIV. One consent to test was not deemed enough. And special counseling has always been recommended for all HIV testing.

So why change the policy? Because things are not at all the same when it comes to AIDS and HIV.

There has been a rapid increase in the occurrence of HIV in younger people who may not be as willing to practice safe sex or for whom those messages sound unnecessary. HIV is also occurring at greater rates in women who do not know about their husbands' various activities -- visiting prostitutes, engaging in gay sex or using intravenous drugs.

These women don't think they are in a high risk group and thus don't get tested.

There are now drugs that really work against HIV, and the sooner they are used the better. Twenty years ago, a diagnosis of HIV meant almost certain death. Today, a diagnosis of HIV is hardly good news, but there is a very good chance that people who are infected can live many years with good medical care.

And we have far more legal protections than we had at the start of the AIDS epidemic. You are not likely to get fired or told you cannot rent an apartment because you are HIV positive. The dire social and economic consequences that once awaited anyone unfortunate enough to have HIV have greatly abated.

What we need is aggressive testing. People who don't know they are at risk need to get tested. People who might benefit from the latest drugs need to get diagnosed. People who might infect others need to know that they could do so and do something about it.

Having doctors routinely offer HIV testing to all patients is a nice first step. Just by taking it, some of the last vestiges of stigma will evaporate from a diagnosis of HIV. But we ought be moving toward requiring HIV testing before surgery, admission to college or giving birth.

It is unlikely that people would be scared away from getting health care by such a requirement, and there is every chance that a few more lives might well be saved as a result.

Old public health policies die hard. Our policy about HIV testing is getting very old and out of date. We ought to let it die.

[All "On Bioethics" columns are archived here]

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