September 21, 2006
Washington, DC -- The American Academy of HIV Medicine has endorsed the revised recommendations for HIV testing in health care settings from the Centers for Disease Control and Prevention (CDC), which recommend significant expansion of routine HIV testing throughout the health care system.
The Academy remains about successful linkages to medical care and prevention services for new positives, as well as around patient privacy, informed consent, and funding to support care for the newly diagnosed. Further, this initiative will generate significant challenges to already under-resourced medical and associated social service systems (including emergency departments, inpatient wards, outpatient clinics, laboratories and social work services).
Despite these concerns, the Academy recognizes the overwhelming necessity of identifying unrecognized HIV infections as a benefit to the public's health and its access to life-saving therapies. "It is crucial that we expand the 'who' and 'how' and 'where' of HIV testing, and we support the CDC's lead on finally putting that in motion," says Dr. Jeff Schouten, AAHIVM Board Chair. "We support the CDC's lead to revolutionize HIV testing in our country's health care settings. We hope to rectify our concerns over insufficiencies and inconsistencies with the CDC guidance; nevertheless, we will work to educate all medical providers on how best to implement these recommendations for their clinics and for their patients."
AAHIVM hopes to reconcile over time the unintended consequences of the implementation of these guidelines including the likely decrease in risk assessment and subsequent risk reduction counseling, the vagaries of how "opt-out" provisions would be defined, and the challenge of linkages from positive test results directly into a good medical care system for patients.
"We feel the CDC's revisions unduly minimize risk assessment and risk reduction counseling for patients of varying risk. Counseling just naturally goes with testing, as diet does to exercise," says Jeff Schouten, Board Chair for AAHIVM. "Though it may not always be feasible to do in-depth risk assessment and appropriate risk reduction counseling with every patient, we also don't want to discourage it either. There needs to be a greater emphasis on identifying community-based prevention resources and facilitating these linkages so the patient who tests HIV negative does not leave the encounter thinking they are not at risk, if indeed they may be." The Academy also strongly supports an "opt-out" approach to testing, meaning that the test is universally offered but that patients can then decline -- but only assuming that all patients tested are told about the test and what the results do and do not mean, and that they be explicitly told they can refuse the test if they want.
"Informed consent does not have to be written nor does it need a patient's signature," says Michelle Roland, Vice-Chair for AAHIVM, "but it does need to be 'real'. We fear that the CDC's recommendations will lead to clinicians simply telling the patient he or she will receive a test. We need to be very clear that there is a likelihood that will happen in many clinical settings; quality assurance activities and continuing provider education on this issue will be critical, but it will also require additional resources and expertise."
Throughout all health systems, AAHIVM insists that direct, dependable linkages to care are absolutely critical to any screening and testing program, especially with public health networks for HIV patients already over-capacity.
"We can't assume that once we discover someone's HIV infection that we'll be able to help and direct them into reliable care," said Dr. Schouten. "It would be irresponsible to take such a significant step with patients and then send them off on their own. HIV care is too complex and too important, and we need to ensure that those doing the testing are confident in deciding the next steps after positive test results." Finally, of course, there is the issue of money. AAHIVM has strong concerns that there are not enough resources, public or private, to fund expanded testing. "Testing more people obviously takes money, and CDC doesn't have it. Who's going to pay for it?" asks Schouten.