Conference explores ramifications of new HIV guidelines

Washington -- Implementing new federal guidelines for HIV screening of most people across all health care settings will be a big job, but well worth the effort, concluded speakers at a recent meeting. But beware of certain hurdles along the way, many cautioned.

On the plus side, earlier identification of infected individuals could result in more rapid entrance into treatment and better outcomes.

Also, if more members of this group adopt safer sex practices, the result could be a decrease in the annual tally of 40,000 newly infected people. There hasn't been a dent made in that number for 16 years, said John G. Bartlett, MD, professor of medicine at Johns Hopkins University in Baltimore and co-chair of the HIV conference, billed as a summit meeting, held in Washington on Nov. 29-30, 2006.

Clinicians, researchers, government officials and behavioral scientists were invited to attend the conference, "Opportunities for Improving HIV Diagnosis, Prevention and Access to Care in the U.S.," to explore how best to implement recommendations, published in September 2006 by the Centers for Disease Control and Prevention.

These guidelines call for nearly everyone ages 13 to 64 to be offered an HIV test. The agency estimates that about 25% of the 1 million Americans with HIV are unaware that they harbor the virus.

Although conference speakers were supportive of the CDC's action, several advised that care must be taken to ensure that treatment is available and affordable and that counseling needs are not neglected.

Acute care settings, inpatient facilities and community health centers are to be first up as the program rolls out, said Robert Janssen, MD, the CDC's director of the division of HIV/AIDS prevention.

He predicted a start in January or February and said the effort will continue into 2008. The CDC will focus first on areas with the highest population of HIV-infected people, said Dr. Janssen.

Several possible obstacles to the new initiative were explored, among them the need to reconcile state and local laws that mandate written consent and counseling with the CDC's recommendation that neither step is required.

Some state laws would have to be changed in order to implement fully the new initiative, said Catherine Hanssens, founder of the Center for HIV Law and Policy in New York City. She urged physicians to become familiar with state and local laws and policies to avoid liability risks.

However, some state laws already have enough latitude to accommodate the CDC's recommendation, said Dr. Janssen. Texas law, for example, requires only a general informed consent, not one specific to HIV, he added.

The Pennsylvania/MidAtlantic AIDS Education and Training Center at the University of Pittsburgh has just published a guide for reconciling laws in nearby states with CDC recommendations. The guide reveals that there is a broad range.

For instance, Delaware law calls for pre- and posttest counseling as well as written consent. The District of Columbia has no laws pertaining to HIV counseling and testing, although the D.C. Dept. of Health has rules for counseling and testing programs.

Reimbursement is another potentially contentious issue.

Dr. Janssen acknowledged that the CDC needs to work with private and public insurers to resolve payment issues. The agency has also requested that three new CPT codes be developed to assist with this goal. Payment for the testing of uninsured patients is also under discussion, he said.

Patient brochures, a Web site and implementation guides are all being developed, said Dr. Janssen.

Counseling and informed consent

Harvey J. Makadon, MD, associate professor of medicine at Harvard Medical School in Boston, who also has a primary care practice, polled fellow physicians about the CDC recommendations. He found that while there was a general sense that providing routine testing would improve their practices, there were concerns.

For instance, physicians would still want to counsel their patients, despite the CDC's separation of testing and counseling.

"Primary care physicians want to do what they are trained to do and like doing, preventing illness and treating symptoms," he said.

Information on best office-based practices and the most effective ways to counsel patients is also needed, said Dr. Makadon.

He suggested that professional groups such as the Assn. of American Medical Colleges or the American College of Physicians might help craft such training.

Reimbursement for time spent and where to even find the time necessary for expanded testing and counseling were other concerns raised by his colleagues, said Dr. Makadon.

Although those in the HIV/AIDS advocacy community also support routine testing, worries exist about the demise of written informed consent, said David Ernesto Munar, associate director for policy and communications at the AIDS Foundation of Chicago.

The advocacy groups question whether verbal consent can be fully informed, said Munar. Plus, they ask whether the voluntary nature of the test would continue to be made clear and whether individuals would be provided a chance to decline the test without facing a penalty.

However, an analysis presented on the tests' cost effectiveness was favorable. Even among populations with low prevalence rates, the screenings are a good use of funds, said Rochelle Walensky, MD, MPH, associate director of the program in epidemiology and outcomes research at the Harvard Center for AIDS Research. Such testing is even more cost effective than such common screening efforts as annual mammograms for women ages 50 to 69, she said.

The analysis, also conducted by researchers at Yale University School of Medicine, was published in the Dec. 5, 2006, Annals of Internal Medicine. They found that routine HIV screening is cost effective even in communities where as few as two in 1,000 people have undiagnosed infection.

The researchers caution that their findings hold true only if those identified with HIV are linked to appropriate treatment.