Health

CDC moves to put HIV testing into routine care

Waiving extensive pretest counseling is one way new recommendations could facilitate widespread screening.

By Victoria Stagg Elliott — Posted Oct. 16, 2006

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HIV testing shouldn't be considered special any more -- at least that's the take-home message of revised federal guidelines regarding HIV testing in health care settings.

According to new Centers for Disease Control and Prevention recommendations in the Sept. 22 Morbidity and Mortality Weekly Report, everyone ages 13 to 64 who receives health care should be offered an HIV test.

The CDC also recommends that specific written consent no longer be required, though patients should be informed that the test is being conducted and have the opportunity to decline. In addition, extensive prevention counseling is not necessary before performing the test or when delivering negative results.

"These new recommendations will make routine HIV screening feasible in busy medical settings where it previously was impractical," said Kevin Fenton, MD, PhD, director of CDC's National Center for HIV, STD and TB Prevention.

In this manner, the CDC's approach marks a shift in thinking. For much of its existence, HIV testing has been bound by special rules because of the associated stigma -- especially in the early days of the epidemic when physicians could offer little help to those who tested positive. Now, with the number of HIV treatments constantly expanding and the taint of the test diminished, public health officials believe that the benefits of widespread screening outweigh any risks.

"It is simply not acceptable for HIV-infected individuals to visit a health care facility without having the opportunity to learn that they have a life-threatening illness," Dr. Fenton said.

The agency regards these new guidelines as one of many steps to increase the number of people aware of their status. Additional implementation guidance and tools for physicians are expected early next year.

The hope is that universal testing will increase the likelihood that those infected will be diagnosed early when treatments are most effective and reduce the chance that they will share the virus. Evidence suggests that those who don't know of their infection status are the source of a significant number of new cases, and that knowledge of positive status can trigger changes in behavior.

"These people have the right to know so that they can seek treatment, and we believe, when they know, they will take steps to protect themselves and their partners," said CDC Director Julie L. Gerberding, MD, MPH.

Several medical societies, including the HIV Medicine Assn. and the American Medical Association, rose to support the guidelines.

"This is an important public health strategy to stop the spread of HIV," said AMA House of Delegates Speaker Nancy Nielsen, MD, PhD.

Positive reviews, yet some concerns

Most physicians interviewed for this article also responded positively to the guidelines, particularly to the idea that initial testing should be offered to everyone. They generally complained that the previous need to use risk stratification to trigger testing was a barrier to even discussing the test with patients. Now, offering it to all may reduce further the stigma and neatly sidesteps the need for patients to be honest about uncomfortable topics they may not want to discuss.

"It will make my job a little easier," said Julie Komarow, MD, a family physician at the Valley Medical Center in Covington, Wash.

But while there was a lot of praise for the CDC's directive, there was also some concern. By far, the issue appearing to generate the most controversy is the recommendation to no longer require extensive counseling in most situations. Some experts bemoan the lost opportunity to educate patients about HIV spread.

"It's going to be dangerous to test people without giving them specific counseling," said Victor Freeman, MD, an internist in Washington, D.C. "I just had myself tested. There was a lot of education, and I learned things I hadn't even thought about. It was incredibly valuable."

Additionally, in some jurisdictions, the recommendations, especially in regard to informed consent and counseling, for now could put physicians at odds with various state laws. Public health officials are optimistic that these statutes will be changed in the wake of these guidelines. The AMA also called for such laws to be reconsidered.

"The AMA asks states to re-examine state legislation to allow physicians to carry out the new CDC recommendations," Dr. Nielsen said.

Those in favor of eliminating the counseling requirements, for instance, said it would allow such discussions to be tailored to the patient's individual circumstances and education level. It also would allow HIV testing to fit more comfortably alongside other medical tests.

"[Extensive counseling] has become a barrier to something else that needs to be done. We don't have a cure, and we don't have a vaccine. But we can give life-saving treatments to those who have it," said Donna Futterman, MD, director of the adolescent AIDS program at Children's Hospital at Montefiore Medical Center in New York. "We have to think how HIV testing is like other routine tests. When we test for diabetes, we don't make patients confess to every hamburger they've ever had."

Still, few believe that counseling will disappear entirely.

"Counseling is a part of what we do," said Cynthia Carmichael, MD, a family physician with Contra Costa Health Services in Richmond, Calif. "That's not going to go away. This will just make testing more available."

Questions also focus on how useful this strategy will be in low-prevalence settings, although the guidelines do take this issue into account. If a medical practice fails to detect one case after carrying out a thousand tests, the practice can cease to offer it routinely.

Meanwhile, many physicians are stressing that the new guidelines will not replace clinical decision-making.

"Physicians will still use their judgment in ordering the test, but it will be easier to discuss testing because of the recommendation," said Frank Landry, MD, MPH, an internist from Burlington, Vt.

Another layer of worry, though, centers on how the health care system will handle treatment if the need increases -- and if such an increase would translate to more funding for HIV and AIDS care.

"Routine HIV testing can save lives. It is the right thing to do," said Daniel R. Kuritzkes, MD, chair of the HIV Medicine Assn. "But Congress absolutely must back up increased testing with funding to match."

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ADDITIONAL INFORMATION

How best to test

Since the development of an HIV test more than 20 years ago, debate has raged over how to use it. Here are the latest recommendations issued by the Centers for Disease Control and Prevention:

  • HIV screening should be performed routinely on all patients ages 13 to 64.
  • Routine screening is optional for practices with a documented HIV prevalence of less than one case per 1,000.
  • Patients at high risk should receive at least annual screening.
  • Testing is encouraged for patients starting a new relationship.
  • Patients are to be notified that HIV screening will be performed and given the right to refuse.
  • Refusal, as well as any positive or negative test results, should be documented in the medical record.
  • A separate written consent form should not be required. General consent for medical care should suffice.
  • Counseling on prevention should not be required before testing or for those who test negative.

Source: Morbidity and Mortality Weekly Report, Sept. 22

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External links

"Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings," Morbidity and Mortality Weekly Report, Sept. 22 (link)

Consolidation of AMA House Policies on HIV/AIDS, Council on Scientific Affairs, June 2003 (link)

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