CDC Urges HIV Tests as Routine in Health Care

ATLANTA, Sept. 21 -- An HIV test should be a routine part of health care for all Americans from the ages of 13 to 64, not just those thought to be at high risk for the disease, the CDC said today.

The recommendation comes as part of a package of new guidelines that also sweeps away previous requirements for pre-test counseling and for a separate written consent for HIV testing.

The goal of the new guidelines, according to CDC director Julie Gerberding, M.D., is to reach the estimated 250,000 Americans who have HIV but are unaware of it. "We know that the only way to diagnose this disease is to get people tested," Dr. Gerberding told a press tele-briefing to announce the guidelines.

Dr. Gerberding said it's estimated that people who don't know their HIV status account for between 50% and 70% of all new sexually transmitted infections in the U.S. Yet people who know their HIV status tend to change their behavior and lessen the risk of transmission.

Under the new guidelines, the CDC said:

• HIV screening would be routine in all medical settings -- from the generalist's office to the emergency room -- for patients from the ages of 13 to 64.
• Patients would be told the test is to be done and that they could refuse it, but the general consent for medical care would include consent for HIV testing.
• Results would be provided in the same way as those of other diagnostic tests, although patients who tested positive would be steered toward counseling and treatment programs.
• Pre-test counseling to explain the risks and benefits of the testing and to explain the meaning of test results would not be required.

A major goal of the new guidelines is to overcome the lack of time that appears to be a barrier to wider HIV testing, said Kevin Fenton, M.D., Ph.D., director of the CDC's National Center for HIV, STD, and TB Prevention.

"Physicians report that the process related to separate written consent and intensive pre-test counseling was often not feasible in busy medical settings," Dr. Fenton told reporters.

Indeed, he said, one study showed that even for patients with other STDs, 76% of emergency room doctors said they never or rarely encouraged HIV testing, mainly because it was time-consuming and they didn't feel qualified to do the counseling.

"It is simply unacceptable for HIV-infected individuals to visit a health-care facility without the opportunity to learn that they have a life-threatening illness," Dr. Fenton said.

If widely adopted, the new guidelines would amount to a major change in clinical practice, with enormous social and economic implications, said experts outside the CDC.

"I believe -- and my organization believes -- that the routine offer of testing is a good thing," said David Munar of the AIDS Foundation of Chicago. "It's certainly a vast improvement over targeting testing to individuals at high risk or in areas of high prevalence."

"Given advances in medical care and the alarming statistic that 25% of those with HIV may not know their status, this is a step in the right direction," he said.

But he said changing requirements for counseling and consent is a step in the wrong direction. "We would like to see more communication around HIV, not only in the medical setting but everywhere," Munar said. "I'm concerned about (physicians) who will integrate this into the routine battery of their blood work and never have a conversation with a patient at all."

The removal of counseling and consent requirements also worried David Holtgrave, Ph.D., of the Johns Hopkins School of Public Health in Baltimore and a former director of HIV and AIDS prevention or the CDC.

"Because physicians are too busy, according to the CDC, let's remove the barriers," he said. "And so the question is are we getting rid of anything that has some benefit."

Pre-test counseling, Dr. Holtgrave said, does have a benefit on its own. Since many Americans don't know much about HIV -- including how it's transmitted and how it can be prevented -- such counseling offers an opportunity to get the information across.

Dr. Holtgrave also noted the increased testing is likely to increase health-care costs. "Where will the money come from?" he asked. "A very important question for any public health policy is what the program is going to cost and where the resources are going to come from."

It's "perhaps premature to make projections" about costs, a CDC official said during the press briefing. Currently, between 16 and 22 million HIV tests are done in the U.S. every year, excluding those used for blood donor screening, said Bernard Branson, M.D.

"It's difficult to gauge what the increase (in testing) will be -- and it will probably be phased in over time -- so we don't have hard figures," he said.

While a major goal of the new program is to identify people who are HIV-positive without knowing it, it's not clear that resources exist to treat many new patients, Dr. Holtgrave said. The Institute of Medicine reported recently that only about half of the 750,000 Americans known to be HIV-positive have access to medical care, he said.

He added that increased routine testing may not reach the majority of those thought to be HIV-positive without knowledge of it. "What is that keeps those quarter-million people from knowing about their HIV," he asked. "Will testing 13- to 64-year-olds address this particular population?"

The concern was echoed by Walter Senterfitt, Ph.D., chairman of Community HIV/AIDS Mobilization, a community group dealing with the pandemic. "A large number of people who arte infected or at high-risk of being infected are not going to be captured in a routine health-care setting because they don't go to one," Dr. Senterfitt said.

He said the new guidelines "if done right" might make a small impact on community transmission of HIV. "But I also think it's being oversold in terms of the benefit," he said, if only because the people most at risk don't use the health-care system.

"For people who are young -- and not pregnant women -- this new initiative is likely to do little," he said.

Other experts interviewed agreed that HIV testing is only part of the issue. Prevention and treatment remain key parts of the equation.

"We do fear that today's announcement somehow signals that testing is a silver bullet against HIV/AIDS, said Munar. "And it's not."