Health
Call for widespread HIV tests has been only partially heard
■ Widespread screening can help curb HIV's spread and connect those already infected with lifesaving treatment, say testing advocates.
By Susan J. Landers — Posted Jan. 5, 2009
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Washington -- Two years after a national call went out to screen nearly everyone for HIV, some progress has been reported, but there's still a long way to go, said experts assembled for a meeting to assess the situation.
Of the 1.1 million people in the nation already infected with HIV, one in five is unaware of that status, according to data presented at the 2008 National Summit on HIV Diagnosis, Prevention and Access to Care. Although these numbers are an improvement over the one-in-four figure announced at the first summit held two years ago, it could be better, said Kevin Fenton, MD, PhD, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.
Efforts to expand testing have yielded small but measurable results, said Dr. Fenton. In 2006, 40% of Americans had ever been tested for HIV; by 2007, 41% had been tested.
But this slight improvement comes in the wake of new CDC figures released last summer showing that many more people in the nation are infected each year than had been thought -- nearly 60,000 instead of the previously estimated 40,000.
Those unaware of their infection are responsible for transmitting between 50% and 70% of new sexually transmitted diseases, said Veronica Miller, PhD, director of the Forum for Collaborative HIV Research, the sponsor of the summit, which was held in Arlington, Va., Nov. 19-21, 2008. The Forum is housed at George Washington University in Washington, D.C., and funded by the federal government and several pharmaceutical firms.
Although a smattering of activity has occurred to follow through on the CDC's recommendation that everyone ages 13-64 be screened unless they decline to be tested, or opt-out, efforts overall have been spotty, said conference participants.
Routine testing still urged
Hundreds of projects across the country show that routine testing is "doable, acceptable and affordable," said Miller. "Testing should be as routine as flu shots."
The availability of a rapid test that can be used in a number of settings has made large-scale screening possible. If the rapid test is positive, a confirmatory blood test follows.
This testing combo is "fast, cheap, easy and almost perfect in terms of a positive and negative result," said conference co-chair John Bartlett, MD, professor of medicine in the division of infectious diseases at Johns Hopkins University School of Medicine in Baltimore.
In addition, screening is highly cost-effective and detects a lethal disease that can be treated, he said. Testing is "a slam dunk."
"But we have to remember the history of the disease," he noted. "It was lethal, carried incredible stigma, the test wasn't very good and there was no treatment."
Tremendous treatment advances have been made in the last decades. Now, early testing can serve as a life saver to those infected, if they are also quickly connected to treatment.
A University of Washington study showed that patients who begin treatment with higher CD4 counts -- just below 500 per cubic millimeter of blood -- fare better than do those who begin treatment when their CD4 counts fall below 350 per cubic millimeter.
Some successful citywide and statewide efforts to expand screening were highlighted at the meeting.
North Carolina, for example, increased testing by 18% from 2006 to 2007, which translates to an additional 25,000 tests administered.
California's Get Screened Oakland has reached 8,000 individuals and tested more than 1,000.
New York City has integrated HIV testing within routine care in a large public hospital system. From fiscal year 2005 to fiscal year 2008, testing increased in that city by 159%.
Some remain skeptical
Many programs have been based in emergency departments, and new data show the testing rate has increased, although not substantially, said Richard Rothman, MD, PhD, associate professor and research fellowship director at Johns Hopkins University Dept. of Emergency Medicine.
Fifty to 100 emergency departments nationwide routinely test for HIV, up from just a handful five years ago, said Dr. Rothman. But there are about 5,000 emergency departments in the United States.
Although conference attendees were supportive of expanded HIV testing, many physicians remain skeptical that testing's benefits outweigh its cost.
For example, surveys of emergency department physicians reveal that many oppose routine testing, citing time constraints and lack of funding.
A study presented at the conference showed that of the 241 emergency and family physicians, internists and physician assistants surveyed at Brown University-affiliated hospitals in Providence, R.I., most preferred the older, 2001 CDC recommendations that called for patients to opt-in to the test.
Those queried said the opt-in approach treated patients with more respect and obtaining specific written consent ensures physicians and patients talk about HIV.
The AMA recommends that testing generally follow the CDC's 2006 recommendations but advises consent be obtained before patients are tested. The consent need not be written.
Meanwhile, the American College of Physicians published guidelines Dec. 1, 2008, as an early release in the Annals of Internal Medicine recommending physicians routinely screen all patients older than 13. The ACP guidelines also advise physicians to determine the need for repeated screening on the basis of an individual's risk for infection.
Patients considered at high risk include those who share injection drug needles or those who had a blood transfusion between 1978 and 1985, according to the ACP.