The United States' health officials confirmed yesterday that from now on they will be urging all adults and adolescents aged 13 to 64 to undergo HIV antibody testing as a routine medical screening test. The US Centers for Disease Control guidelines, published on Thursday in Morbidity and Mortality Weekly Report, recommend that everyone should get tested at least once, and that people at high risk of HIV infection should take an HIV test at least once every year.
The change in stance on testing has been under discussion for several years, and is broadly supported by doctors, HIV advocacy groups and public health officials as a way of reducing the number of people diagnosed late in the course of HIV disease, when treatment may be less effective.
“We urgently need new approaches to reach the quarter-million Americans with HIV who do not realize they are infected,” said Dr Julie L. Gerberding, CDC director. “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.”
In order to make testing more straight forward pre-test counselling will be kept to a minimum, and instead of signing a separate consent form for the HIV antibody test, patients will be considered to have given consent when they sign a standard medical consent form covering all routine procedures.
“When women have their annual OB/GYN exams,” said Dr Arlene Bardeguez, director of HIV services at New Jersey Medical School, “the physicians don’t have to do counselling and consent to test for syphilis and gonorrhea or to do their Pap smears. It’s standard-of-care. The patients expect us to provide them with diagnosis and treatment as needed. What you don’t know can hurt you. That is why we hope HIV testing will become standard-of-care, too.”
CDC says that patients should 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 with basic information about HIV and the meanings of positive and negative test results, and should have the opportunity to ask questions.
Additionally, CDC continues to encourage prevention counselling for all patients where feasible, “especially when the health care visit is related to substance abuse, sexual health, family planning, or comprehensive health assessments.”
However, CDC also says that one of the reasons for dropping a requirement for prevention counselling for all people tested is because of time constraints in healthcare settings and because many doctors are uncomfortable about initiating discussions of sexual behaviour with patients.
Patients at high risk of HIV infection, who will be encouraged to test at least once a year, are defined as all heterosexuals and men who have sex with men who have had more than one sex partner since their last HIV antibody test, or whose sex partners have had more than one sex partner since their last test. Injection drug users and their partners, persons who exchange sex for money or drugs and sex partners of HIV-positive people are also included in this category.
Healthcare providers should encourage patients and their prospective sexual partners to be tested before initiating a new sexual relationship, the guidelines state.
CDC points to evidence that awareness of HIV status reduces risk behaviour. “In a meta-analysis of findings from eight studies, the prevalence of unprotected anal or vaginal intercourse with uninfected partners was on average 68% lower for HIV-infected persons who were aware of their status than it was for HIV-infected persons who were unaware of their status,” the recommendations state.
The new guidelines also emphasise the need for increased vigilance during pregnancy, with the recommendation 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 labour for all women whose HIV status remains unknown at the time of delivery.
Whilst AIDS advocacy groups have been generally supportive of the new recommendations the American Civil Liberties Union said yesterday the new regulations raise serious privacy concerns. Virtually every state in the nation now collects the names of those who test positive for HIV. Many states also require doctors to report private information, such as drug use and sexual history about those who test positive.
“HIV discrimination is still rampant in this country. People continue to lose their jobs and housing because they have HIV. If the government is going to invade people’s privacy by collecting the names and deeply personal information of people with HIV from their doctors, at a very minimum, people deserve to know that this information is being collected and how it is going to be used,” said Rose Saxe, a staff attorney with the ACLU AIDS Project.
“Health care providers should also inform patients if anonymous testing is available, so that people can make an educated decision about where to get tested.”
Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents and pregnant women in health-care settings. MMWR 55 (RR-14): 1-18, 2006.