Widespread HIV testing is urged

The Baltimore Sun

Federal health officials recommended yesterday that HIV testing become a routine part of medical care for everyone ages 13 to 64, reversing old guidelines that directed most tests to people considered at high risk.

Under the policy, announced by the U.S. Centers for Disease Control and Prevention, tests would be offered by primary care doctors and in emergency rooms, community health centers, substance abuse programs, prisons and other settings where patients receive care.

Routine tests would reach many of the estimated 250,000 people in the U.S. who unknowingly carry the virus that causes AIDS, Dr. Julie L. Gerberding, the CDC director, said in a conference call. They account for a quarter of infected Americans, according to government estimates.

"We believe that when they know, they will take steps to protect themselves and their partners," Gerberding said. Early diagnosis can also help people start treatment before their condition is advanced and harder to treat, officials said.

"It is simply not acceptable for HIV-infected individuals to visit a health care facility without being able to learn they have a life-threatening infection," added Dr. Kevin Fenton, acting director of CDC's division of HIV and sexually transmitted disease prevention.

Testing for the virus is a critical public health issue in Baltimore and Washington, which have some of the highest infection rates in the country. Three months ago, Washington adopted a similar policy that recommends routine testing in medical settings.

Although many doctors and public health experts hailed the CDC recommendations, others said they were concerned that physicians don't have the time to counsel patients about the meaning and potential repercussions of a positive test.

The new guidelines would also expand HIV testing of pregnant women to prevent transmission to their babies. Existing guidelines for tests early in pregnancy have helped reduce the number of infected newborns from 1,650 in 1991 to fewer than 240 last year, officials said.

Now, women would also be tested in their third trimester to catch infections that occur during pregnancy.

If widely adopted, the policy will make HIV screening as much a part of general medical care as Pap smears, cholesterol measurement, mammograms and other common tests. But patients would not be screened with every exam; only those who initially test positive would be steered toward repeat testing.

The policy would require that patients consent to HIV testing and be given the chance to opt out. But to streamline the process, the CDC says doctors no longer have to get patients to sign separate consent forms for HIV testing. Instead, patients would verbally approve the test along with other routine lab work.

Similarly, the agency said that doctors do not necessarily have to counsel patients about the implications of a positive result before testing. Instead, counseling could be limited to patients who test positive.

Federal medical privacy laws ensure that the results of a patient's HIV tests would not become available to insurance companies and other third parties without the patient's written consent, said Dr. Bernard Branson, associate director for laboratory diagnostics in the CDC's office of HIV prevention.

For patients, however, safeguarding HIV test results can be a tricky matter.

Dr. Richard Boehler, chief medical officer of St. Joseph Medical Center in Towson, said patients are routinely asked to sign releases that give insurance companies broad access to test results. Savvy patients can exclude certain tests from outside inspection by indicating so on the forms.

By and large, doctors and health care organizations praised the CDC's action, saying that wider testing will help stem the epidemic and combat the perception that HIV is limited to certain risk groups such as drug users.

"I think some people assume, inappropriately, that HIV is only a disease of certain classes of individuals," said Boehler. "We know from managing patients in the hospital that HIV does exist and occur in those that we'd consider lower risk."

But some were concerned that routine testing would overburden hard-pressed doctors who weren't likely to get paid for the extra time it takes to test and counsel patients.

Dr. Daniel Levy, president of the Maryland chapter of the American Academy of Pediatrics, said he has problems with the ethics of not counseling patients about the implications of a positive test ahead of time.

"That goes against everything that's ever been taught," said Levy, who practices in Owings Mills. "It flies in the face of the training of every pediatrician."

Levy said he'd like to see research demonstrating that such widespread testing of the American population is cost effective.

The CDC's Branson argued that routine testing would be cost-effective for the recommended age groups because it would catch the infection before it becomes expensive to treat and prevent transmission to partners.

Although HIV has become more common among older Americans, the agency decided that tests for people 65 and older wouldn't turn up enough positives to justify the expense, he said.

The recommendations, published in the CDC's Morbidity and Mortality Weekly Report, are the culmination of a three-year process in which officials sought the input of doctors and professional organizations.

Although local public health officials have expected the CDC recommendation for months, many said yesterday that they needed time to digest the details.

Dr. Joshua Sharfstein, Baltimore's health commissioner, said the CDC "made a compelling case" for routine HIV testing, but his office will continue long-standing efforts to reach high-risk populations with mobile testing vans and other measures.

Dr. David Holtgrave, a professor at the Johns Hopkins Bloomberg School of Public Health, said he agrees with the policy's goals but has several concerns. Without counseling patients who test negative, he said, doctors could miss the chance to learn about their drug use or risky sexual practices - and warn them.

Holtgrave, who directed CDC's HIV prevention efforts from 1997 to 2001, said it's unclear whether routine testing will pick up a large portion of those who are infected but don't know it.

Perhaps, he said, those people aren't being tested now because they don't get much health care at all.

"By targeting people 13 to 64 in routine medical care, is that going to pick up that other 250,000 people?" he said. "I hope it does that right away. Will it or won't it is a question that remains to be seen."


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