CDC wants routine HIV testing for all

In order to increase the number of people aware of their HIV status and encourage physician office-based testing, the Centers for Disease Control and Prevention intends to release guidelines as early as this month urging that everyone between ages 13 and 64 be tested for the virus at least once in their lives. In addition, extensive pretest counseling will no longer be recommended if the test occurs in a medical office.

"We need to expand access to HIV testing dramatically by making it a routine part of medical care," said Kevin Fenton, MD, PhD, director of the CDC's National Center for HIV, STD and TB Prevention.

This move is the latest in a series of public health efforts to help people infected with HIV receive treatment early in the viral course, when interventions are most effective. Experts believe this window is often missed because infection status is not known. In addition to improving outcomes for those who already carry the virus, officials also note that increased testing may reduce transmission because people are more likely to change their behavior if they know they are putting others in jeopardy.

"If you identify those who have it, they can be treated. They can prevent spread to others," said Nancy H. Nielsen, MD, PhD, speaker of the American Medical Association's House of Delegates. "Testing should be more routine."

The CDC recommendations are generally consistent with AMA policies, which also state that the physician's office and other medical settings are the preferred venues for HIV testing, and that physicians should work to make counseling and testing more available in these places.

In anticipation of the recommendations, many physicians are optimistic that removing the link between HIV testing and certain behaviors may reduce the stigma associated with getting or being offered the test.

"It's really unfortunate that HIV has been perceived as reflecting someone's sexual preference or drug use," said Keith Hansen, MD, chair of the department of obstetrics and gynecology at the Sanford School of Medicine of the University of South Dakota. "Hopefully we have all recognized that it's a disease that doesn't have preferences. This [recommendation] makes it more like any other disease that affects humans."

Additionally, many say scrapping what is sometimes considered an onerous requirement for extensive in-office pretest counseling will make the practice more common.

"Getting rid of [it] makes performance of the test much more routine," said Dr. Nielsen.

It would also allow physicians to tailor counseling to the needs of the individual patient.

Some doctors, however, see a downside to this specific recommendation, arguing that it would translate into a lost opportunity to provide education about risk reduction and could lead to fewer doctor-patient discussions about the test itself.

"Getting rid of pretest counseling in the clinical setting is likely a mistake," said Robert Garofalo, MD, MPH, president of the Gay and Lesbian Medical Assn. and director of adolescent HIV services at Children's Memorial Hospital in Chicago. "In an ideal world, testing for HIV would be no different from testing for diabetes or Chlamydia. That's not the world that we live in. Patients need to be making an informed and educated decision before having the test done."

This change may also be at odds with some local laws. According to a compendium of testing statutes compiled by the National HIV/AIDS Clinicians' Consultation Center, at least 12 states mandate pretest counseling for all who take the HIV test. Experts predict, though, that these requirements would eventually be brought into line with the CDC position.

"Things will get harmonized, and we'll be much better off for it," said Daniel Kuritzkes, MD, chair of the board of the HIV Medicine Assn.

Implementation questions

Meanwhile, others are raising issues of practicality.

Some physicians, particularly those who work in areas where HIV is less common, are concerned that screening everyone without taking risk factors into account will be expensive and could trigger a high rate of false positives. This situation could, in turn, lead to significant anxiety without detecting many new cases.

"I think HIV should be tested for like any other sexually transmitted disease, such as syphilis or gonorrhea. Having said that, I also don't think that every adult should get a gonorrhea or syphilis test. Any decision about screening should be based on a patient's medical conditions and their risk factors," said Douglas S. Parks, MD, associate professor of family medicine at the University of Wyoming. Wyoming has had just a few hundred cases since the epidemic began 25 years ago.

Questions about who will pay for all of this testing also are rising.

"Insurance companies are very leery of paying for screening tests. If we're going to recommend it, we have to make sure that it's a covered service," said Donna Seminara, MD, director of geriatrics at Staten Island University Hospital in New York.

Finally, some physicians wonder whether downstream funds will exist for the increasing number of people who test positive and, therefore, will need services.

"It's great to recommend all this testing, but somebody's got to make sure there are funds for care," said Howard Grossman, MD, executive director of the American Academy of HIV Medicine.