By David Brown
Washington Post Staff Writer
Friday, September 22, 2006
All adolescents and adults should routinely be tested for HIV infection in hospitals, clinics and doctors' offices, the federal government said yesterday, signaling a radical shift in the public health approach to the 25-year-old epidemic.
Under the new recommendations from the Centers for Disease Control and Prevention, patients would no longer have to sign a consent form and get extensive pre-test counseling. But they would have to be told they were being tested for the AIDS virus, asked if they have any questions and given the opportunity to "opt out."
The policy is a huge change from an era when stigma and fatalism led to a unique and -- in the opinion of some practitioners, onerous -- set of procedures for HIV testing.
"This represents a milestone for CDC and for our national health protection," Julie L. Gerberding, the CDC's director, said in a telephone news conference.
Universal HIV testing is part of an all-out effort to address three problems that many experts view as scandalous: 250,000 Americans are infected with HIV and do not know it, 40 percent of infected people are diagnosed when their infection is already at an advanced stage, and the number of new infections annually in the United States has not declined in 15 years.
If medical providers go along, the strategy may be able to reduce the number who do not know they are infected by two-thirds. Because many of those people are highly likely to pass the virus on -- either because of their behavior or because they are in an early stage of the disease, when more virus is in their bloodstream -- that could in turn help prevent new cases.
By rolling an HIV test into routine blood testing to measure blood sugar, kidney function, hemoglobin count and myriad other health indicators, the policy would make AIDS unique in another way. It would become the only infectious disease tested for more or less automatically in medical encounters. Pregnant women are tested for AIDS, syphilis and hepatitis B, but the CDC policy would cover everyone 13 to 64 years old.
Advocates for AIDS patients generally lauded the new strategy but expressed concern that it could lead to occasions when people are not told they are being tested or are not prepared to handle the results.
"It's all in the implementation," said David Munar, associate director of the AIDS Foundation of Chicago. "I am concerned that in some settings that patients will be shortchanged."
Marjorie J. Hill, executive director of Gay Men's Health Crisis in New York, said her organization agrees "that HIV testing needs to be expanded and that the procedures need to be streamlined as far as possible." But she added: "It is also important that the individual who is the object of these procedures and information have meaningful, informed consent. For some people that may be a two-minute conversation. In others it may take longer."
Between 16 million and 22 million HIV tests are done each year in the United States. CDC officials would not speculate on how much that might increase.
Newly identified cases of HIV are reported to local health departments in most states, and under another CDC policy they will soon be reported in all. That allows public health officers to help get those people into care and in some cases to trace sexual contacts.
Practically speaking, the goal is to have everyone in the age range tested at least once, and high-risk people tested at least once a year. Low-risk people do not have to be tested each time blood is drawn.
The District began a campaign three months ago to make HIV tests a routine part of visits to emergency rooms and physicians' offices. This week, officials said 3 percent of people tested at community health sites are infected -- about twice the national rate.
HIV testing is a two-step process. An initial test, called an ELISA assay, screens for antibodies against the virus. If it is positive, a more specific test, called a western blot, is performed. The price ranges from about $8 to $80, which includes the cost of counseling. The lower figure is for a negative ELISA, the higher for a positive test that would require a western blot and more extensive post-test counseling. Rapid HIV tests, which give results in 20 minutes, cost about $20 more.
The expense of expanded HIV testing would be borne by the current payers of medical care -- insurance companies, the government, hospitals and clinics, and patients. If a medical institution finds that fewer than 1 in 1,000 HIV tests are positive, it can drop routine testing.
Testing regulations differ around the country, and some states will need to change laws to follow the recommendations. Virginia does not require a separate consent form for HIV testing, but Maryland does.
The new recommendations say that "patients should be informed orally or in writing that HIV testing will be performed unless they decline. . . . Information should include an explanation of HIV infection and the meanings of positive and negative test results, and the patient should be offered an opportunity to ask questions and to decline testing."
CDC officials emphasized that while HIV testing may become routine, following up positive tests will still require specific attention.
"Active efforts are essential to ensure that HIV-infected patients receive their positive test results and linkage to clinical care, counseling, support, and prevention services," the recommendations say.
One of the CDC's main goals is to lower the practical and psychological barriers faced both by people offering HIV tests and by those getting them.
The emergency department of Johns Hopkins Hospital in Baltimore set out to offer testing to every patient eight months ago but has found that goal difficult to achieve.
"The legal requirements for written consent in the state of Maryland take time and effort beyond what is feasible in a busy emergency department," said physician Richard E. Rothman.
He said the department recently began using a "facilitator" who counsels patients and gets consent. That has "dramatically increased" the number of tests offered. About 50 percent of patients are now asked, and about 75 percent of them agree.
"Patients are definitely interested in being tested. There is no doubt about that," Rothman said.
Public health officials also hope the shift will help further destigmatize HIV. When the CDC recommended in 1995 that all pregnant women be tested, many clinics found that women embraced the policy, as it no longer required them to identify themselves as "at risk" to get tested.
The benefits of knowing -- and the hazards of not knowing -- one's HIV status are clear from studies. Between 54 and 70 percent of sexually transmitted cases of HIV are transmitted by people who do not know they are infected with the virus.
Once people know, most take precautions. The frequency with which a person has unprotected intercourse, homosexual or heterosexual, falls by about 50 percent once that person knows his or her HIV status. But the rate of unprotected sex may remain as high as 40 percent in some groups.