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GMHC Statement on Proposals to Expand HIV Testing and Care

April 4, 2006

As New York City, and the entire world, approaches the 25th anniversary of the beginning of the HIV/AIDS epidemic, Gay Men's Health Crisis joins others in the community in focusing on what must be done to stop the spread of AIDS and HIV infection and to move us towards a city and a world without AIDS.

Here in New York City, we face many challenges including racial and ethnic disparities in the number of AIDS-related deaths, new cases of HIV infection and disproportionately high rates of HIV incidence and prevalence among populations such as black and Latina women, gay and bisexual men of color and young gay men of all races.

Given these realities, we all must do more. GMHC strongly believes that everyone has the right to accessible and voluntary HIV counseling and testing, HIV prevention education and services, and quality care and treatment. GMHC wholeheartedly supports the goals of reducing the number of people who do not know their HIV status, increasing the early detection of HIV infection, and assuring that all New Yorkers living with HIV promptly receive the best medical care available to them.

Voluntary HIV counseling and testing are essential components of the strategies needed to achieve these goals. Various approaches to increasing the number of people who are tested need to be explored, including the routine offering of HIV counseling and testing in health care settings. GMHC supports new approaches to HIV counseling and testing. However, we believe strongly that counseling and testing must be voluntary, and include meaningful written informed consent, with information on what an HIV test means, along with linkage to care and prevention for both those who test positive and negative. Increasing the numbers of people tested is not enough.

Over the past year, New York City's Commissioner of Health and Mental Hygiene, Dr. Thomas Frieden, has proposed several approaches to the same goals widely shared by GMHC and others in the community. These proposals include significant modifications to New York State Public Health law 27F to streamline pre-test counseling and substitute documented oral consent for written consent when conducting an HIV test. We commend the Commissioner on promoting increased dialogue on HIV/AIDS issues, particularly focused on stopping HIV.

Nonetheless, we have a number of concerns with the proposals as stated and with the vagueness of some of them. GMHC is particularly concerned over the proposed plan to eliminate the requirement of written informed consent to HIV testing.

GMHC's recommendations to reach the stated goals are as follows:


Restructuring HIV Testing and Counseling Procedures

GMHC supports efforts to increase access to voluntary HIV counseling and testing and to remove any barriers to getting more people tested. These include making HIV testing and counseling a routinely offered component of medical care, and streamlining testing and counseling procedures. This process has already begun with the increasing availability of rapid HIV tests and changes in HIV testing and counseling procedures implemented last year by the New York State Department of Health.

However, GMHC opposes changing the law to remove the requirement for written informed consent. We are convinced that written consent should continue to be required to ensure that HIV testing remains voluntary in practice and not just in theory, that patients do not simply acquiesce to being tested, are not in any way made to feel coerced and that they fully comprehend the array of ramifications associated with the testing results. In addition, it would appear from a legal standpoint that providers would enjoy greater protection from possible legal challenges with signed written consent forms than from oral consent documentation.

In addition, there needs to be procedures instituted to assure that those with positive test results are referred and linked to appropriate medical care at the point of diagnosis. Upon receiving their results, all individuals should have access to HIV prevention education and services, including prevention counseling as needed, to facilitate behavior changes that will prevent further transmission and enable those who test negative to remain HIV negative.


Provider Training and Linkage to Care

As a practical matter, physicians do not routinely engage in conversations with patients about their sexual activities and behavior. GMHC recommends that medical providers be given sufficient training with regard to issues of sexuality and HIV/AIDS to have this discussion with their patients and educate them around their health and safety. We believe that enhancing the physician/patient relationship around issues of sexuality will produce the results we are all seeking -- encouraging people to get tested and know their status, and reducing HIV transmission. Furthermore, promoting patient/doctor discourse increases client awareness, compliance and future treatment adherence.

We urge the city to use its leverage as the administrator of the largest municipal health system in the country to establish a training program with New York's medical training facilities that will enhance the provision of medical services to all individuals, particularly those most at-risk of being infected, such as the Lesbian, Gay, Bisexual Transgender community, people of color, and women.

We believe HIV counseling and testing, linkage to care and linkage to HIV prevention are especially important in communities with a high prevalence of HIV and believe that there are significant gaps in these services that must be addressed.


Community Involvement

In line with the universal desire to remove any barriers to HIV testing, GMHC is supportive of routinely offering HIV testing in medical settings, but also recommends expanding HIV testing and counseling offered by community based organizations, along with the involvement of members of the community. This type of grassroots effort has a demonstrated record of success in getting people tested and referring them to appropriate medical care, and should be continued. As an example, with the increased availability of rapid testing, GMHC recently launched a mobile testing van that has captured the attention of at-risk individuals who might not otherwise have sought out testing.


Stigma

Testing for HIV is not the same as testing for cholesterol. Telling one's family that you have HIV as opposed to cancer is likely, even in 2006, to elicit a response that is less than supportive. Being diagnosed as HIV-positive carries overtones of sexual transmission, and is often linked to substance use and being gay, all of which carry stigma.

Given the realities of our environments, it is imperative for someone about to take an HIV test to understand the implications of the test and its results. Maintaining counseling will not only help individuals cope with the test results if positive, but also help people who test negative stay negative.


Restructuring Patient Monitoring Procedures

All individuals entering the testing process should be assured that they have access to the best quality medical care.

The Commissioner proposes changing Article 27F of the State's Public Health Law to allow the New York City Department of Health and Mental Hygiene to contact providers and their patients when reportable laboratory test values indicate unaddressed problems with their medical care.

Doctors and testing facilities currently report positive HIV tests and AIDS diagnoses to the department. Additionally they report HIV RNA tests that measure the amount HIV in the blood, CD4 cell counts that reflect the health of the patient's immune system, and resistance tests, which assess the susceptibility of the patient's virus to HIV medications.

GMHC is concerned with the vagueness of the proposals and their application to changes to Article 27F. We are also concerned that, as presented, the proposals blur the distinction between legitimate public health interventions and individual health care.

We are seriously concerned with the vague nature of these proposals, most notably the lack of discussion regarding resources needed to implement the level of monitoring recommended.

GMHC sees some potential for an important intervention if newly infected people who are highly infectious are able to be identified and linked to care. However, it seems there are already protocols in place for identifying this population, and for providers to respond. The public needs to see much more compelling data in order to be assured that overhauling state law is necessary.

Provider performance is an area of major concern and we see nothing in the current state law that prevents a public health agency from reaching out to those providers in a non-patient specific way in order to promote standard practices. We would strongly support efforts to provide routine updates on treatment for providers and believe that this is an appropriate role of a public health agency.

GMHC commends the Department of Health and Mental Hygiene and Commissioner Frieden for opening a dialogue on these issues, and hopes that in this spirit of partnership the Commissioner will bring more people living with and affected by HIV/AIDS, providers, community leaders and organizations together to craft a truly common vision for the health of city and stopping the HIV/AIDS epidemic.




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