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CDC Recomendations
Sep 26, 2006

Dr. Bob Today I read in the press where the CDC and AMA want to start testing everyone 13-64 for HIV. They want to make it a part of everyones annual physical just like a annual cholesteral test. The article also stated that they were going ot do away with the seperate "informed consent form " that one usually signs to be tested for HIV. It stated that HIV testing would be covered under the Clinic or hospitals "Standard Care Consent Form". The article did say that you would be allowed to "opt out" of HIV testing. But how would you know to opt out if you don't know the test is part of your standard testing package? How will patients know which test are covered under the "standard Care Consent Form"? I can see lots of potential abuses coming out of this decision. What do you think?

Response from Dr. Frascino

Hello,

These new guidelines have been three years in the making and are a significant break from HIV policy that has been in place for the past two decades. The concept is that HIV screening would remain voluntary, but instead of asking patients if they would like to take the test, doctors would tell patients they will be tested unless they specifically say no ("opt out"). The CDC also recommended dropping pre-test counseling sessions and the separate consent form for HIV testing.

So what do I think? Well, I have mixed feelings about these new guidelines. It's easy for the CDC and AMA to say that HIV testing should be just like cholesterol screening. However, no one is ever fired from a job for having high cholesterol. And I doubt anyone ever gets divorced because of a cholesterol test. But putting that aside, there are both potential upsides and downsides to instituting this new policy.

On the upside: I'm in favor of more testing. There are an estimated quarter-million Americans who are infected with HIV and do not know it. (25% of the total one-million Americans estimated to be HIV positive.) More testing could help identify these folks and get them into treatment earlier, before their immune systems are shot. We might be able to prevent a number of HIV infections if more HIV-positive folks knew their status.

On the downside: there is a concern this policy will be more like mandatory rather than voluntary testing. As you mentioned, how are folks supposed to know they can "opt out" if the busy emergency room staff just draws the blood as a routine test? I'm also concerned with the recommendation to do away with pre-test counseling. Pre-test counseling is an excellent opportunity to discuss HIV prevention and basic treatment issues. There is also the issue of a negative test being misinterpreted (i.e. testing during the window period, false-negatives, etc). Finally, I wonder about the cost. Is it really the best use of limited HIV health care dollars to spend it on screening large numbers of folks in areas with an extremely low incidence of HIV? Congress, in their infinite "wisdom" (read: stupidity), is preparing to cut millions of dollars which had been earmarked for HIV/AIDS treatment and care programs in hard-hit cities, such as New York, San Francisco and Los Angeles. If this plan passes, the Republicans in Congress will strip 29.6 million dollars from San Francisco's allotment of the Ryan White CARE Act money over the next five years. I would hope that any guideline changes that increase testing would link that to access to care and treatment.

I also worry that in order to fund this program, money will be shunted form other HIV prevention and treatment programs.

Can a program like the one the new guidelines suggest really work to identify new HIV cases? Yes, I think it can. A pilot program offering free testing with written consent has been underway since January 2005 at Highland Hospital in Oakland, CA. They tested over 8,000 people and found 101 new HIV-positive patients. HIV, like many other diseases, is actually cheaper to treat if it's caught early.

So the new program has both "the good" (more testing), "the bad" (cost, shifting limited resources, loss of counseling, its less "voluntary" nature, chance for misinterpreting results, etc.) and . . . well, let's hope it doesn't also have "the ugly" (identification of new HIV patients without linking them to care, discrimination issues due to "names reporting" of all HIV-positive folks, less money available for other prevention efforts and programs).

Stay tuned. We're all curious how this will play out.

Dr. Bob


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