CDC calls for routine testing to stem HIV infection rates

While the guidelines should increase the number of patients tested, there are concerns about inadequate pretest counseling.

By Victoria Stagg Elliott, AMNews staff. May 19, 2003.

In the past three years, Marshall Kubota, MD, a Santa Rosa, Calif., family physician, has had four patients die of AIDS-related complications. Two of them received the AIDS diagnosis on their hospital deathbeds.

Stories like this are part of the motivation behind the Centers for Disease Control's new HIV prevention guidelines published last month in the Morbidity and Mortality Weekly Report.

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According to the guidelines, HIV testing should be like any medical screen or test provided by a primary care physician, and pretest counseling should be simplified to work in this setting. Testing should also be routine for pregnant women or their newborns if the mother has never been tested.

Ways should be found to utilize the rapid-results test outside the medical setting, and public health prevention messages should be targeted to people who are already HIV-positive in an effort to stop the infection's spread.

"This new initiative is exciting and it capitalizes on new, rapid testing technologies, provides us the opportunity to reduce barriers to testing, enhances prevention services and continues to prevent mother-to-child HIV infections," said Harold Jaffe, MD, director of the CDC's National Center for HIV, STD and TB Prevention.

The CDC is attempting to address what public health officials believe are the major obstacles to improving AIDS morbidity and mortality. AIDS-related deaths plummeted in the mid-1990s after the introduction of anti-retrovirals, but this progress has since plateaued. New infections also appear to be inching upwards.

"It's simply unacceptable that 40,000 people in this country become infected with HIV each year, and it's intolerable that about one-fourth of those infected with HIV don't know they're infected and therefore are not receiving appropriate medical care," said CDC Director Julie Gerberding, MD, MPH. "This new initiative will go a long way to help frontline clinicians help people overcome some of the barriers they face getting diagnosed and treated for HIV."

Most aspects of the plan have been praised. Routine HIV testing for pregnant women is the law in many states and the policy of several medical associations, including the AMA and the American College of Obstetricians and Gynecologists. Some states mandate testing for newborns if their mother has not been tested.

Counseling concerns

The shift of testing out of the specialist clinic and into the purview of primary care, particularly since the CDC is taking the emphasis off extensive prevention counseling, has raised a lot of concern. Several AIDS organizations, for instance, agree that it is a good idea for more people to know their status, but express dismay that people may not receive prevention counseling in the process.

"Every individual undergoing a medical procedure or test -- particularly for something as significant as HIV -- has a right to know and understand what [is being] recommended and to decide whether to give informed consent," said Pat Christen, executive director of the San Francisco AIDS Foundation.

Many doctors, however, praised the new guidelines as possibly making HIV testing more feasible for low-prevalence settings.

They also said the change may increase recognition that not everyone who is positive will necessarily fit neatly into a high-risk category.

"I understand the unpopularity of the decreased counseling position," said Dr. Kubota. "But we're talking about a different population. We have methodologies of testing that reach high-risk people. We have to reach populations beyond that, and to do that, strategies have to be different."

Physicians working on HIV issues also hope that the guidelines will lead to more doctor involvement in HIV screening and diagnosis, as well as a reduction in the disease's stigma.

"We've been way behind in doing our share in case-finding, and there's so many missed opportunities in the world of physicians," said Donna Futterman, MD, associate professor of pediatrics at Albert Einstein College and director of the adolescent AIDS program at Children's Hospital at Montifiore in New York. "This is long overdue. It's still viewed as a big taboo. This will go a long way to destigmatizing HIV and bring into care the 300,000 people who have HIV and still don't know."

Her office has conducted surveys of local health institutions suggesting that physicians find current HIV testing protocols too complex and time-consuming for routine use. They responded that they don't perceive their patients to be at risk. They also said they tested for STDs three times as often as they did for HIV.

"We have to be willing to try other things to make this more routine," said Dr. Futterman. "Programs that can provide more extensive counseling should do it, but the absence of all those resources should not mean ignoring HIV testing."

While most physicians praise the CDC's goals, not all are so keen about the plan to reach them.

Specifically, there is some concern that the slimmed-down counseling aspect may get more people tested, but may leave them with little information about what do to with the results.

"I'm delighted that the new guidelines may make more clinicians offer HIV testing," said Cynthia Carmichael, MD, staff physician at Contra Costa Health Services in Richmond, Calif. "It should be routine, but you should not de-link HIV testing from adequate counseling."

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