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2 Perspectives on HIV Testing

More than 250,000 Americans are HIV positive but do not know it. To reach this population—25 percent of HIV-positive Americans—the CDC has recommended that HIV testing become a routine part of medical care for people ages 13 to 64. Is this the best solution?

A pair of top AIDS experts share their informed views.

Prioritize Testing

With a new HIV infection roughly every 13 minutes in the U.S. and an AIDS-related death roughly every half hour, clearly expansion of HIV counseling and testing services is a priority. Though well-intentioned, the CDC's recommendations for more HIV testing in health care settings have three critical flaws.

  • They recommend HIV testing for all people 13 to 64 years old in all clinical settings. If testing resources were unlimited, this would be desirable, but given our sadly limited resources, we should prioritize geographic areas (like Baltimore) and venues (such as emergency departments) with high HIV prevalence so we can diagnose as many people living with HIV as quickly as possible. (As resources become available, expansion can move into lower prevalence arenas.)
  • While the CDC recognizes the need to get people diagnosed as HIV positive into care and treatment, they have failed to develop with other federal agencies a detailed plan for a sure and speedy pathway to comprehensive, high-quality care.
  • The CDC states that counseling is not required to accompany testing in health care settings. Discarding such client-centered counsel-ing is to throw away a critical, science-based intervention that can modify risk behaviors and prevent sexually transmitted diseases.

For these reasons, I support the spirit of the CDC's recommendations, but have serious concerns about the details. Instead, I suggest a major expansion of a variety of HIV prevention interventions in the U.S., including an expansion of testing services. These expanded testing services should include client-centered counseling, guarantee quick access to high-quality care and treatment and, if resources remain limited, prioritize high-prevalence areas and venues to identify and rapidly get into care as many people living with HIV as possible. Time is of the essence. As a society, we should be judged by how quickly and how well we expand HIV-related services. As a nation, we have the skill. It is now a matter of will.

David Holtgrave, PhD, oversaw HIV/AIDS services in the U.S. as director of the CDC's Division of HIV/AIDS Prevention. He is chair of the Bloomberg School's Department of Health, Behavior and Society.

Test Everyone

The reasons to make this a standard test are to help the effort to prevent HIV transmission and save lives with early treatment. A few points:

  • The prevention effort has failed. There have been an estimated 40,000 new cases of HIV infection in the U.S. every year for 18 years. People who know they are infected take precautions. The estimate is a 31 percent reduction in new cases if we could find the 250,000 people who are HIV positive and do not know it.
  • Treatment is a great success, but nearly half of the patients do not learn of HIV until they have had the infection 8 to 10 years and enter treatment too late. Our calculations for Maryland are about 2,700 life years lost (which means 270 people died 10 years prematurely due to late diagnosis). And yet all of those people have been to emergency rooms, clinics, etc., many times without having been tested.
  • Some are worried that we need to mandate counseling, but most studies show little impact and none show any decrease in HIV transmission. The CDC position is that counseling is fine and should be done as it is with other sexually transmitted diseases. It should not be law just for this one.

The goal is to test everyone once. It is a cheap, rapid test and cost-effective. If a person's test comes back positive, there is easy access to care and medications due to federal programs, especially the Ryan White Care Act.

In 25 years in HIV care, I do not know any patient who could not get care or the drugs they needed.

John Bartlett, MD, is a professor of Medicine in the Division of Infectious Diseases at Johns Hopkins School of Medicine and a professor of Epidemiology at the Bloomberg School.

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