AMA meeting: Consent should be required for HIV testing, AMA says

Honolulu -- Physicians should routinely test their adult patients for HIV but ought to obtain informed consent before they do so, according to an ethical opinion adopted at the AMA Interim Meeting last month.

The policy is generally in line with 2006 Centers for Disease Control and Prevention guidelines, but AMA policy requires patient consent.

"The new CDC guidelines say that simply consenting to general medical care implies consent for an HIV test, but we believe that specific and full informed consent is imperative, especially considering the consequences of an HIV-positive result," said Kavita Shah, a medical student member of the Council on Ethical and Judicial Affairs.

The informed consent need not be written or documented, and testing without prior consent is OK in limited cases, such as when health care professionals are potentially exposed to HIV, the ethics policy states.

An estimated 25% of those infected -- about 250,000 Americans -- are unaware that they are living with HIV.

Doctors should ensure that those who test positive get the follow-up care and counseling they need, the new policy says. Physicians also should comply with disease reporting laws while protecting their patients' privacy as much as possible.

Lastly, the AMA policy says, doctors are obligated to notify public health authorities if they believe a patient "poses a significant threat of infecting an identifiable third party."

If the law allows, they should notify the patient's partner without revealing the patient's identity.

Physicians have been slow to adopt the CDC's new guidelines, saying they lack the time to test patients they view as being at low risk for the disease.

More than half the states have laws requiring informed consent or follow-up counseling for HIV testing. Also, funding for routine testing has been in short supply. Some delegates voiced these concerns before adopting the new policy.

"Expansion of HIV testing is laudable, but we have a concern about routine testing and how that will be applied," said Pino D. Colone, MD, an emergency medicine physician who spoke on behalf of the Michigan State Medical Society delegation. "The judicious use of HIV testing is appropriate, but if this policy is adopted, any physician who doesn't do routine HIV testing would be deemed unethical."

Other delegates called the new ethics policy a universal testing mandate, a characterization that AMA Trustee Ardis Dee Hoven, MD, rejected.

"All this policy says is that just as you would ask a patient about getting a flu shot or a Pap smear, you should be offering her an HIV test," Dr. Hoven said.

Legalizing partner therapy

In a related matter, the House of Delegates directed the AMA to support legislation that would let doctors provide medications for gonorrhea and chlamydia to infected patients to give to their sex partners.

But delegates asked CEJA to reconsider a report that offered ethical guidance to physicians implementing this practice, known as expedited partner therapy. Though the CDC adopted guidelines for the practice in 2006, it is legally permissible in only 11 states.

Fewer than 5% of physicians notify the sex partners of patients they have treated for a sexually transmitted disease, and asymptomatic patients may be unwilling or unable to seek care.

Four CDC-funded randomized controlled trials found that patients' partners had significantly fewer recurring infections using expedited partner therapy versus traditional care methods.

But fewer than a dozen states permit the practice, which some physicians have used for years in quasi-legal fashion. The ethical concern is that the practice could undermine the traditional physician-patient relationship.

The CEJA report argued that expedited therapy is acceptable so long as physicians use it as a secondary option for patients unable or unwilling to seek traditional care.

A CDC representative said relegating the expedited therapy to secondary status sends the wrong message to doctors.