More backing for broad, routine HIV testing

When Karla Demby, MD, sees patients, she takes a history and, on that basis, decides whether she should offer the patient an HIV test. In her opinion, offering it to everyone just doesn't make sense.

"There are fairly well-defined risk factors for HIV disease, and I don't think it's extremely difficult to delineate them in a primary care practice," said Dr. Demby, an internist from Cortez, Colo.

Still, the common practice of using a history as the initial screen for HIV is coming under scrutiny as routine screening is increasingly considered a possible strategy for diagnosing more people with the infection.

Most recently, two papers in the Feb. 10 New England Journal of Medicine used computer models to suggest that routinely screening every patient for HIV infection, at least once, and possibly as often as every three to five years, might be cost-effective.

"HIV testing turns out to be a comparatively good value, and as a society, we'd be better off," said A. David Paltiel, PhD, lead author of one of the papers and chair of the division of health policy and administration at the Yale School of Medicine in Connecticut.

Benefits include allowing more HIV-positive patients access to available medications sooner, which would likely lengthen their lives. On a populationwide basis, such screening could reduce spread, because medications suppress viral load and reduce the chance of transmission. Also, those who know they are positive tend to take more precautions.

"The benefits to the patient of being identified early and getting into treatment are so large that it really makes sense to screen," said Gillian Sanders, PhD, the second study's lead author and an associate professor of medicine at Duke University in Durham, N.C.

A persistent and prickly debate

Public health experts estimate that as many as 280,000 people have HIV without being aware of it. In an effort to reach them, the Centers for Disease Control and Prevention launched an initiative in April 2003, with the support of the American Medical Association, to make HIV testing a routine part of medical care.

The matter, however, is extremely contentious. Debates at AMA meetings often have been heated, although official organization policy says those who suspect they have been exposed should be tested and that testing should be readily available for all who want it. Routine testing is recommended in certain situations, such as for neonates in states with a high prevalence of the disease and for sexual assault victims.

The AMA opposes mandatory testing for the general population. Still, some individual physicians support the idea.

For example, survey data released last month by HCD research, a market research firm in Flemington, N.J., suggested that 64% of physicians thought mandatory, federally funded HIV testing would improve the overall health of the population. These data, however, were not published in a peer-reviewed journal, and few doctors believe the approach is workable.

"From a practical standpoint and from a patients' rights standpoint, I don't think we're ready for mandatory testing," said Kevin Larsen, MD, assistant professor of internal medicine at the University of Minnesota. "But it's really time that [routine testing] enter our consciousness."

Although there is growing evidence that more routine screening could be the way to go, many specifics remain unclear. The screening interval is a matter of fierce debate, and the most practical way of carrying it out is murky. Much of the burden also likely would fall on the shoulders of primary care physicians.

Patients want testing

A study published in the January Journal of the National Medical Assn. found patients wanted to be tested routinely for HIV by their primary care physicians, even if they didn't consider themselves at high risk.

"It would be a fabulous undertaking to make HIV testing more routine," said Emma Simmons, MD, MPH, lead author and assistant professor of family medicine at Brown University in Providence, R.I. "And if you do it in a primary care setting, then you have linkage to care, and you might even lower the costs because you would be able to prevent an infection before you have to treat it in a hospital."

But evidence suggests that many primary care physicians are less than eager to take on this responsibility. Data collected by the American Academy of HIV Medicine and expected to be published in April found that a quarter of physicians currently did no HIV testing, primarily because of concerns about post-test counseling.

"There's a significant proportion of practitioners who aren't doing testing at all, and I'm not even clear if they have the resources to refer people to someone else," said Howard Grossman, MD, executive director of the Academy. "As for the New England Journal articles that recommend routine testing, I would maintain that doctors are not ready to do it."

Cost is a major concern. This intervention might be cost-effective, but many insurers will not pay for an HIV test in a patient who is asymptomatic. It also seems unnecessary to test patients at low risk of infection.

"In this day and age where we're looking at reducing health care costs, you're going to have a lot of opposition from insurance companies, because they're going to have to pass this cost onto the customers, and, as a taxpayer, I'm not sure I want to be paying for all Medicaid and Medicare patients to be HIV tested," said Pink Folmar, MD, an internist from Birmingham, Ala. "A lot of people don't need to be tested."

Physicians also said some patients might avoid medical care altogether if HIV testing is a bigger part of the visit. And, they said, the loss of the patient-physician conversations that could lead to HIV testing would be detrimental to overall medical care.

"What researchers who are doing population studies may not always appreciate is how well we get to know most of our patients," Dr. Demby said. "I still see this as a disease that the screening should be a history, and [with that] you learn much more about your patients other than just their HIV risk."