Washington All adolescents and adults should routinely be tested for HIV infection in hospitals, clinics and doctors' offices, the federal government said Thursday, signaling a radical shift in the public health approach to the 25-year-old epidemic.
Under the new recommendations from the Centers for Disease Control and Prevention, patients would no longer have to sign a special consent form and get extensive pretest counseling. However, they would have to be told they were being tested for the AIDS virus, asked if they have any questions and given the opportunity to "opt out."
The new policy is a huge change from an era when stigma and fatalism led to a unique and - in the opinion of some practitioners, onerous - set of procedures for HIV testing.
"This represents a milestone for CDC and for our national health protection," Julie Gerberding, CDC's director, said in a telephone news conference.
Universal HIV testing is part of an all-out effort to address three problems that many experts view as scandalous: 250,000 Americans are infected with HIV and do not know it; 40 percent of infected people are diagnosed when their infection is already at an advanced stage; and the number of new infections annually in the United States has not declined in 15 years.
If medical providers go along, the strategy may be able to reduce the number who do not know they are infected by two-thirds. Because many of those people are highly likely to pass the virus on - either because of their behavior or because they are in an early stage when more virus is in their bloodstream - that could in turn help prevent new cases.
Ages 13 to 64
By rolling an HIV test into routine blood testing to measure blood sugar, kidney function, hemoglobin count and myriad other health indicators, the policy would make AIDS unique in another way. It would become the only infectious disease tested for more or less automatically in medical encounters. Pregnant women are tested for syphilis and hepatitis B, but the CDC policy would cover everyone ages 13 to 64.
AIDS community groups generally lauded the new strategy, but they worried it could lead to occasions when people are not told they are being tested or are not prepared to handle the results.
"It's all in the implementation," said David Munar, associate director of the AIDS Foundation of Chicago. "I am concerned that in some settings that patients will be shortchanged."
Marjorie Hill, executive director of Gay Men's Health Crisis, in New York, said her organization agrees "that HIV testing needs to be expanded and that the procedures need to be streamlined as far as possible." But, she added, "It is also important that the individual who is the object of these procedures and information have meaningful, informed consent. For some people, that may be a two-minute conversation. In others, it may take longer."
Between 16 and 22 million HIV tests are done each year in the United States. CDC officials would not speculate on how much that might increase.
People newly identified as HIV-positive are reported to local health departments in most states, and under another CDC policy will soon be reported in all. That allows public health officers to help get those people into care and in some cases to trace sexual contacts.
Practically speaking, the goal is to have everyone in the age range tested at least once, and high-risk people tested at least once a year. Low-risk people do not have to be tested each time blood is drawn.
HIV testing is a two-step process. An initial test, called an ELISA assay, screens for antibodies against the virus. If it is positive, a more specific test, called a western blot, is performed. The price ranges from about $8 to $80, which includes the cost of counseling. The lower figure is for a negative ELISA, the higher for a positive test that would require a western blot and more extensive post-test counseling. Rapid HIV tests, which give results in 20 minutes, cost about $20 more.
The expense of expanded HIV testing would be borne by the current payers of medical care - insurance companies, the government, hospitals and clinics, and patients. If a medical institution finds that fewer than 1 in 1,000 HIV tests are positive, it could drop routine testing.
The new recommendations say that "patients should be informed orally or in writing that HIV testing will be performed unless they decline. ... Information should include an explanation of HIV infection and the meanings of positive and negative test results, and the patient should be offered an opportunity to ask questions and to decline testing."
CDC officials emphasized that while HIV testing may become routine, following up positive tests will still require specific attention.
"Active efforts are essential to ensure that HIV-infected patients receive their positive test results and linkage to clinical care, counseling, support, and prevention services," the recommendations say.
One of the CDC's main goals is to lower the practical and psychological barriers faced by people offering HIV tests and those getting them.
The benefits of knowing - and the hazards of not knowing - one's HIV status are clear from studies. Between 54 and 70 percent of sexually transmitted cases of HIV are transmitted by people who don't know they are infected with the virus.
Once people know, most take precautions. The frequency with which a person has unprotected intercourse, homosexual or heterosexual, falls by about 50 percent once a person knows his or her HIV status. However, the absolute rate of unprotected sex may remain as high as 40 percent in some groups.