September 25, 2006

Routine HIV Testing for Everyone. A Good Idea If You Can Sell It

The CDC finally has issued its recommendations that all adults and teenagers in the United States be offered routine HIV testing as part of their annual physical – assuming they get an annual physical. Of course, we’ve been discussing the ethics of routine HIV testing in the bioethics and public health community for decades, focusing on issues of privacy, stigma and discrimination – fiddling, some argue, while cities like New York and San Francisco burn. The grim fact is that the number of new HIV infections has hovered around 40,000 newly infected individuals per year since 1990, regardless of whatever new prevention strategies and messages public health officials and advocacy groups have dreamed up. Maybe the CDC’s recommendations can help. A surprising number of HIV-infected individuals in the United States are completely unaware of their serostatus. They’ve never been tested, either because they do not believe that they are at risk or because they won’t ask their doctor for testing out of embarrassment or fear of revealing that they are gay, a drug user, or the sexually active teenage daughter of the local evangelical minister.

Even before the likely recommendations of the CDC task force first became known in May of this year, several states, districts and municipalities hardest hit by the HIV epidemic had already begun to explore new ways of increasing awareness and testing. Consider, for example, the District of Columbia’s campaign this past summer urging every resident between the ages of 14 and 84 to be tested for HIV.

So what happens now that we have federal guidelines for routine testing? Now comes the fun part, as individual states consider whether or not to adopt the CDC recommendations, if they even can under existing state laws. Thomas Frieden, the New York City health commissioner, already is on record as saying he agrees with the new recommendations and reportedly has been actively lobbying the New York State Legislature to incorporate them into the state’s Public Health Law. But here in my adopted state of New York we also have some of the nation’s strictest privacy protections, with the law requiring HIV counseling and voluntary informed written consent prior to testing (unless, of course, you’re a pregnant woman – we also are one of only two states with mandatory HIV screening of newborns, and detection of HIV antibodies in the infant’s blood automatically reveals the mother’s positive serostatus). Contrast these laws with those of my home state, California. California does not require separate written consent for an HIV test, and the San Francisco Department of Public Health recently amended city policy to eliminate the need for written consent there.

From my own experience as an HIV researcher in New York, I can tell you that HIV counselors in the state are already overwhelmed; there are too few counselors, too many patients, and not enough money in already tight public health and hospital budgets to train and hire more. So do we weaken these privacy protections, as Dr. Frieden would seem to advocate? New York City officials proposed this last summer, holding a series of meetings in which they proposed changes to New York’s HIV testing laws, including abolishing the requirement for separate written consent for an HIV test. Needless to say, those meeting didn’t go so well. Representatives of civil liberties groups and organizations that serve people with AIDS were outraged.

There still are a number of unanswered questions about routine HIV testing. For example, do the benefits of universal screening outweigh the costs and risks, given the wide disparity in HIV infection rates between the various states? Who will pay for expanded screening, particularly as Medicare is not allowed to pay for routine screening tests unless specifically authorized by Congress?

The feds have weighed in. It’s now up to the laboratory of the states to find the answers.
Sean Philpott, Executive Editor

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