Prevention
By Sharon Egiebor
Click here to see CDC recommendations The Centers for Disease Control and Prevention’s recommendation that voluntary HIV testing become part of routine medical care should increase the number of people who know their HIV status, according to doctors and those who advocate an increase in national testing. Although the testing is a positive step, it should be treated as one action in the process of reducing the rate of HIV infections, doctors and AIDS activist say. Dr. Keith Rawlins, medical director of the Peabody Clinic in Dallas, said the concept of signing a general consent for all medical care is an important thing to do. “I support the idea of doing testing in this manner because it really makes it easier for people to find out their status. If you don’t want to know, you can say, ‘I don’t want to know,’” said Rawlins. Rawlins said the new recommendations should work well in private settings and in emergency rooms where timing becomes critical. He and others expressed concerns on the effects the additional testing may have on the health care industry and for the people who will test positive. Rawlins, whose practice mainly consists of HIV/AIDS patients, said the increase in testing is going to raise the demand for more knowledgeable medical personnel, which may be difficult for some people to get. The care will depend on an individual’s geographic location, economic status and whether or not they have health insurance, he said. On Thursday, the CDC issued new recommendations that health care providers implement routinely test for HIV, without a separate or additional consent form from patients. “We urgently need new approaches to reach the quarter-million Americans with HIV who do not realize they are infected,” Dr. Julie L. Gerberding, CDC director, said in a news release. “People with HIV have a right to know that they are infected so they can seek treatment and take steps to protect themselves and their partners.” The CDC said the new recommendations are designed to overcome several barriers that hindered implementation of the earlier recommendations, which called for HIV testing for patients in health care settings with high HIV prevalence (above 1 percent) and for all high-risk individuals. Implementation of these recommendations was difficult because many health care facilities do not have information on HIV prevalence, and many providers report that they do not have sufficient time to conduct risk assessments. Physicians also report that the processes related to separate, written consent and pre-test counseling for HIV testing have posed significant barriers. In surveys and in consultations held by CDC, health care providers consistently reported these time-consuming processes were not feasible in emergency rooms and other busy health care settings. Secondly, Rawlins said, “once you get to an experienced clinician, you need the medication. If you can’t get to the medication or can’t afford the medication, you are not going to get the particular outcome you want.” Dr. David Malebranch, an assistant professor at the Division of General Medicine at Emory University’s School of Medicine in Atlanta, agreed with Rawlins that making the test as routine as a mammogram or colonoscopy should increase the number of individuals who know their HIV status. “We still have a way to go make sure that it is not just targeting specific groups,” he said. “From my understanding, some of the language is a little bit strange because they still focus on risk groups men-who-have-sex-with men (MSM) or heterosexuals who have had sexual relations with drug users or MSM. But if you have had unprotected anal or vaginal sex, you are at risk for HIV. “You could say because you are a MSM, you need an HIV test, but if they use condoms every time or only have one partner, then they don’t need an HIV test every year.” Malebranche, who supervises health care providers-in-training at the Urgent Care Center at Grady Hospital in downtown Atlanta, also sees his own panel of patients at the Ponce Infectious Disease Center, a local AIDS clinic in Atlanta. Malebranch said he has long advocate for and taught his residents that any patient who is sexually active should take an HIV test. Many people, he said, felt he had gone overboard. “The definition of a good screening test is one of that is going to actually reduce morbidity and mortality,” he said. “Not only do people get their tests results, they are more likely to wear condoms or disclose to their partners, they have a higher likelihood of being treated.” Part of the controversy of routine testing is whether or not doctors – private or public – will take the time to explain the results to a patient. Under the new recommendations, the CDC is suggesting doctors could forego the pre-test counseling. Privacy advocates also are concerned that doctors will include the HIV test in the routine panel without the patient’s knowledge. ”Historically, in academic institutions and clinics, you have an uninsured population and a population that has less health literacy,” Malebranch said. “There is a problem and a very real sense of expectation that goes on there that someone can get an HIV test without their consent. “The job upon us, especially those who work in academic settings like I do, is to encourage better training of our residences that this is not a free license to do an HIV test. They still have to be prepared to do testing for both positive and negative results. We have been doing that at Grady for a while -- teaching how to ask about sexual history and how to give good news and bad news.” The subjective feelings of a medical provider have been too frequently used in deciding who should take an HIV test, he said. “That is a byproduct of supporting risk groups, rather than risk behavior,” he said. For instance, medical personnel may assume a homosexual black male should have an HIV test, whether or not he engages in risky sexual behavior, while ignoring a white, married heterosexual woman who may be engaging in anal sex or have multiple partners. Malebranch says this results in skewed results of who is HIV positive. “ If you screen a certain population more frequently, you get more of those people testing positive.” CDC’s recommendations were developed over a three-year period with extensive input from health care providers, public health experts, community-based organizations, and advocates nationwide. Major components of the new recommendations include: · HIV screening for all patients, regardless of risk: Despite prior CDC recommendations for routine testing for high-risk individuals and for all patients in settings with high HIV prevalence, many patients with unrecognized HIV infection access health care but are never tested for HIV. To normalize HIV screening as a routine part of medical care, the revised recommendations advise that all patients aged 13-64 be screened. · Voluntary, “opt-out” approach: CDC’s recommendations strongly emphasize that HIV testing must be voluntary and undertaken only with the patient’s knowledge. The recommendations advise that patients be specifically informed that HIV testing is part of routine care and have the opportunity to decline testing. Before making this decision, patients should be provided basic information about HIV and the meanings of positive and negative test results, and should have the opportunity to ask questions. · Simplified testing procedures: To overcome the most significant barriers to testing in health care settings, the recommendations advise that pre-test counseling and separate, written consent for HIV testing should no longer be required. Consent for HIV testing can be incorporated into general consent for medical care. Regarding counseling, the recommendations underscore the need to ensure that patients who test positive for HIV are provided prevention counseling and linked to ongoing care. Additionally, CDC continues to encourage prevention counseling for all patients where feasible, especially when the health care visit is related to substance abuse, sexual health, family planning, or comprehensive health assessments. · Enhanced screening for pregnant women: Existing CDC recommendations for routine prenatal HIV screening have already contributed to remarkable success in preventing mother-to-child HIV transmission in the U.S. The estimated number of infants born with HIV declined from a peak of approximately 1,650 in 1991 to fewer than 240 each year today. The new recommendations are intended to help reduce this number even further. They state that repeat HIV testing should be provided in the third trimester not only for women at high risk for HIV, as current recommendations advise, but also for women in areas with high HIV prevalence among women of childbearing age or in facilities with at least one HIV diagnosis per 1,000 pregnant women screened. They also specify that a rapid HIV test should be used during labor for all women whose HIV status remains unknown at the time of delivery.