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Tuesday, May 9, 2006

Routine HIV Testing—Just Say Yes

Posted by on May 9 at 11:36 AM

The CDC is recommending that we change our approach to HIV testing.

Testing for the AIDS virus could become part of routine physical exams for adults and teens if doctors follow new U.S. guidelines expected to be issued by this summer.

Federal health officials say they would like HIV testing to be as common as a cholesterol check….

One-quarter of the 1 million Americans with the AIDS virus don’t know they are infected, and that group is most responsible for HIV’s spread, CDC officials said.

I agree 100% with Georgia10 at DailyKos:

We cannot stop the AIDS epidemic with a rate of 24%-27% of undiagnosed carriers. Making AIDS testing as common as an ordinary blood test can go a long way to dealing with this health crisis.

If everyone who carried the virus knew his or her HIV status, it would significantly reduce the infection rate. It wouldn’t eliminate new infections, of course, but it would bring it way down. Not only would more people who are currently infected know that they had to take steps to protect their sex partners, routine HIV testing would also mean that more people who are infected would get treatment—and treatment seems to make HIV-positive people less infectious by reducing their viral load, which would further cut the infection rate. It would also lead to more, and more effective, sero-sorting, the practice of positives seeking out other positives as sex partners, and negatives seeking out negatives. Sero-sorting is credited with reducing the infection rate in San Francisco, of all places.

Wow! Routine testing for HIV would save lives—so naturally the AIDS establishment is opposed to the CDC’s sensible recommendation:

Some patients’ advocates have voiced concern that the recommendations do not include pre-test counseling and sufficient informed consent.

You can read GMHC’s take here, and San Francisco AIDS Foundation’s take here.

Perhaps the CDC’s proposal can be tweaked—who could object to more counseling?—but the primary reason AIDS orgs will oppose the new guidelines is that many do little more than encourage people to get tested and offer HIV tests. If HIV tests become a routine part of regular medical care—and it should—it will be harder for many HIV orgs to justify their expensive, ineffectual existences.

Please don’t listen to the AIDS orgs on this issue: It’s past time that we began treating HIV like other sexually transmitted diseases. That means routine testing, names reporting, and contact tracing—all routine public health measures that will save lives, particularly the lives of African American women.

In a side note: One of the problems with HIV prevention education in this country is the slogan “Be Safe—Get Tested,” which creates the impression that testing is safety. I know lots of gay men who regard regular testing as some sort of retroactive absolution for whatever unsafe or risky activities they participated in between tests.


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The only problem I would have with it is how the insurance companies would react. Would they/could they dump you or jack up your policy if they see you are positive? How will employers react? Would they/could they dump you from their group policy if they find out you are positive?

Of course, if we were sensible and would just open medicare up to everyone, this wouldn't be an issue. I'm usually fairly retro in my sensibilities, but this 1940's way of insuring people just sucks.

Dan,

I wholeheartedly agree with you that there are a lot of ineffectual HIV orgs out there. I find it interesting that there are more and more people interested in "starting an HIV organization," from scratch, from ever-dwindling HIV prevention funds. Unfortunately, the CDC source-of-all-major-funding doesn't operate on "survival of the fittest/leanest/most efficient" policies, but rather on the beliefs of whatever political party is in power (which means we are all screwed until at least 2009).

But I digress. I've worked in HIV/syphilis prevention/education/testing/partner notification/social work for over 10 years, and I totally see the "Be Safe - Get Tested" thing as fallacious reasoning, especially for gay men. If somebody continues with risky behaviors, but continues to test negative, they either think, "Gee, I must be doing something right," or worse, yet, "I must be immune." [I once counseled a guy that swore that vaseline (and nothing else) was keeping him negative all these years. His test came out negative; how could I convince him otherwise?]

Which is why your last paragraph seems to contradict everything else you said in your blog. How is the "routine testing" plan different from "Be Safe - Get Tested?" I think it will also lull people into thinking that just because they regularly test negative, they must therefore be "safe."

Let me tell you first-hand, there are a TON of people that are cajoled into testing for HIV (say, as part of chlamydia testing and treatment), and if people are not really ready to be tested, they sure as heck won't stick around/come back for the results, and (take it from me), they sure as HELL don't want to be found, especially if their results are positive.

Also, with dwindling resources for HIV/AIDS treatment, and with an ever-increasing number of people testing positive (especially with the CDC's unbrilliant strategy of mass-testing without accompanying counseling), are we really doing anyone any favors, by saying, "OK, I know you didn't really want to test, and aren't ready for these results, but congrats, you're HIV positive. Sorry, Ryan White funds have been cut again, so you're on a 1-year waiting list to get CD4, etc. testing paid for, and pretty much have to wait for somebody to DIE before you can get on the AIDS-drugs waiting list." ?

While I dread the results of the CDC's new "routine testing" incentive, I do agree with your beliefs in holding people personally accountable for their actions. I'm an HIV-negative gay man (here but for the grace of goddess), and it's pretty much a miracle that I'm still negative, as over half of my ex's are now positive, and I can guaran-fucking-TEE you that they didn't give a rat's ass about my health or safety. I am 35 and negative BECAUSE I PROTECTED MYSELF.

Teach people that they MATTER, and that they have to look out for themselves - not that it's the government (and taxpayer's) responsibility to test them, give them the bad news, and pay for their treatment.

Keep up the great writing (even if I disagree with it sometimes)!

Peace Out

BTW - I wouldn't be so heavy on the praise to San Fran on being so forward-thinking on lowering HIV rates. The midwest et al. are always looking to San Fran as the source of the "next best thing" in HIV prevention. WAKE UP, HEALTH DEPARTMENTS! San Fran is usually the first place to find the "worst new thing" - crystal meth, STD's du jour, etc. You are perfectly capable of coming up with your own, effective prevention techniques - believe in yourselves! Or at least look to Seattle - their needle exchange program has done a kick-ass job of keeping down the rates of new IDU-transmitted HIV infections.

| Wow! Routine testing for HIV would save lives--so
| naturally the AIDS establishment is opposed to the
| CDC's sensible recommendation

Please define the term... AIDS establishment

| "Be safe--Get Tested"

Note every time that this term is used referring to
preventing sexually transmitted infections
the correct term is always...
safer

There's never zero risk.

Regarding the comment about health coverage insurance, can you name a case, an example?...

All's there has to be is a few cases of that and that will be the end of that. It's a disease and should be treated as a disease.

Regarding the thought experiment...

The strategy.
Get tested together for a variety of sexually transmitted infections including human immunodeficiency virus and share the results with your potential sex partner BEFORE having sex.

Here's the collaborative blog and wiki about the strategy of let's get tested together BEFORE we have sex... for STDs
http://NotB4WeKnow.blogspot.com

"Regarding the comment about health coverage insurance, can you name a case, an example?..."

Read my comments again, please. What I was asking was how would routine testing affect health insurance coverage and rates for people who were found to be positive. I don't trust insurance companies to do the right thing, and neither does anyone else who is of normal intelligence. That's the only flaw I can find with routine testing.

I am a straight, white, non-drug using, sexually active female which puts me at a very low risk of contracting HIV, however, at my yearly exam last year, I asked to be tested, "just in case". My doctor actually DISCOURAGED me from doing it unless I had a specific partner that I thought had put me at risk, because according to her, my insurance premiums would go up. I decided against it, I can't afford to have even MORE money come out of my paycheck... You could tell my doctor felt bad about disocuraging me but at the same time, she knew I couldn't pay more for my insurance. Talk about fucked up...

Excellent post. I think it's terrible that we didn't do this 20 years ago.

It wasn't until a couple of years ago that the horrible math of HIV struck me. If the average HIV+ person transmits it to more than 1 person, the epidemic spreads. It won't go away until the average infected person spreads it to less than 1 person.

On the issue of insurance
First of all, V--you mentioned not wanting to have more money coming out of your paycheck. If it is actually coming out of your paycheck (rather than a cute way of saying "I don't want to have to pay more for my private insurance"), that implies some sort of group health insurance plan. With those, everyone in a group of employees with the same coverage comes with the same premium (meaning you, or your employer, pay the same). It's all done in the aggregate, so they couldn't raise 1 person's premiums. Plus, past experience of a group is just 1 thing that goes into determining rates for a group, and i think that there has to be substantial health costs before a group of insured employees could point to that variable as being the sole cause for premiums going up.

But, if getting tested raised individual plan premiums, that is fucked up.

I think the CDC's rec is good. From what I've read, it's just a rec, and not binding on any doc. Plus, it's been explained as being routine as regular cholesterol testing, or some of the tests we women get on a regular basis. And just like any of those, the patient has the right to decline them (to say nothing of the fact that the patient has to go to the doctor's to even be offered). I turn down the STD tests some of the time, because I'm married and pretty sure my husband is monogomous (every few years, when the doc asks, i may accept, just to be safe). I'd probably get the HIV test once, and then wouldn't do it every year (I hate a blood draw). I don't think they're imagining that this is going to make a big impact on the groups who actively try to evade the test results, as Tester described. Rather, I think it's just an attempt to, over time, increase the number of people who are tested each year, and thereby decrease the % of undiagnosed people.

There are several issues that still need to be worked on. Like the counseling component. And ensuring that insurance companies can't penalize people as a result. And making sure that we're prepared for all of the issues that go along with an increase in the number of patients being treated for HIV (drug supply, costs, accessibility). But it's a good step.

I'd love to get tested for STDs routinely at my physicals. However, the ugly spectre of insurance company redlining rears its head - the physical is being done by my HMO. What if that HMO then decides that a positive result on, say, human papilloma virus or HIV means an automatic rate increase, or denial of coverage? That would be seriously fucked, and would - DOES - deter people from getting tested.

I agree, Geni, and if there aren't already mechanisms in place to prevent against those things, it's surely something that's going to become more important.

With testing for human papilloma virus, it's in an insurance company's best interest to not penalize women for being tested (and even testing positive) for HPV, because even if you test positive, it's still cheaper to deal with it early than to have to pay for treating the cervical cancer that may develop. For the most part, the economics advantage of incentivizing preventative care and early treatment for any issue have led insurance companies to prioritize just that. Not sure how the economics works out when you compare treating a healthy HIV-positive patient for 20 years to the cost of treating full-blown AIDS and its complications.

I think the CDC's suggestion is a step in the right direction for normalizing HIV testing. If it's something you do every year like clockwork, then it takes some of the anxiety out of it. Of course, a positive result is terrifying, but a positive result for HPV on a pap smear is also scary. Thousands of American women every year die of cervical cancer, but avoiding getting tested isn't going to make the threat of cancer go away, just like avoiding HIV testing isn't going to make the virus go away.

I don't know if a positive result on an HIV test would suddenly make insurance premiums go up. Do they go up if a patient is diagnosed with cancer? One thing that is certain is that, if a person is diagnosed with HIV, they are going to have to receive treatment. If they have insurance, they're going to need to use it and, obviously, they're going to have to tell the insurance company that they're HIV positive. Insurance companies can't suddenly drop a patient, or deny coverage, if they're diagnosed with a disease.

What concerns me about standardized testing is what happens to people who are uninsured. If you're diagnosed with a serious condition and you're uninsured, then you'll never get insurance. However, a solution might be to continue anonymous testing. If a patient doesn't have insurance, they can pay the forty bucks out of pocket for an anonymous test. If the result comes back positive, then the patient can buy some health insurance before they start treatment.

keshmeshi, Insurance companies can and do cut people off when they get serious diseases. And they routinely deny coverage due to pre-existing conditions. We have some protections here in Washington State, but there is now talk of drafting legislation that would elminiate state-by-state protections.

Don't kid yourself. Insurance companies don't want to cover people with serious health problems.

How devious of you, Keshmeshi. Unfortunately, that would be insurance fraud, and it wouldn't take long for insurance companies to find a way to respond. There are publically-funded insurance plans for uninsured folks diagnosed with significant medical problems like cancer, but it's not the same.

And I think you've hit on the main problem--it's getting insurance if you go uninsured at some point. Once a company decides to insure you, I don't think your insurance company can really jack up your rates b/c of a diagnosis, even if you are on an individual plan. Your rates are set on a contractual basis, and even for individual plans, they're not calculated down to the individual. When they decide to raise the rates for the contract year, they do it for the particular group--either for the employer, or for individuals within a certain age group.

But this is just a tiny part of the many things that need to be considered regarding health insurance in the US. Just one more thing to complicate the very difficult process of fixing a system that seems near collapse.

I promise, that's my last post on the inner-workings of health insurance.

This is interesting... a few years ago, my niece was having surgery and all of the family members were asked to have their blood typed to see if we could donate. When I went to get typed, my doc suggested that I go ahead and get tested for HIV because if I was a match and donated blood and the hosiptal found the virus in their testing of the donated material, they might or *might not* be able to tell me because of their consent processes (for example, if I gave blood here and had it shipped to where she was having surgery, they wouldn't be able to tell me because I wasn't there to give direct consent).

And I had a few other tests done at the same time, so I seriously can't see how the insurance companies could object to HIV testing becoming routine. There are way too many situatons where it's pretty much required/suggested. And heck, I know my routine pap smear appoinment includes testing for all the other STDs - without me having to ask.

I'm not sure how I feel about the counseling deal, either. People being tested for cancer or other abnormalities and diseases don't get routine counsleing as to what might happen if the results come back positive... they get the counseling afterward. I know many women who've had to go in to get lumps in their breasts checked and were wracked with nerves and such before, during, and after the tests, awaiting the results and no counseling was required or offered. So I'm not sure how I feel about pre-counseling being required. And if that is an issue that might prevent routine testing for HIV, it makes me want to forgo that counseling easily.

> That's the only flaw I can find with routine testing.

What do you mean?... a flaw

You could apply that same anxiety or fear to testing blood
before transfusion or testing kids for tuberculosis
before you let them in school.

Check out this introduction article on HIV test:
http://www.articleworld.org/index.php/HIV_test

Yeah but who will test homeless and the poor? And they are the potential carriers.

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