Pre-test counseling and written consent would also be ended

by Anthony Glassman

Atlanta--The federal Centers for Disease Control and Prevention on September 21 issued a new recommendation for across-the-board HIV testing for everyone aged 13 to 64 as part of their regular medical care.

The CDC plan calls for the testing to remain voluntary, but would remove requirements for written consent in states where such consent is now mandatory. The document would also allow states to adapt the program as necessary. The CDC also called for an end to pre-test counseling.

The guidelines ask that everyone in the affected age bracket be tested at least once, and that people in high-risk groups be tested annually.

AIDS service organizations and the government estimate that one-quarter of people with HIV, about 250,000, do not know they are infected, and so do not seek treatment or ensure that they engage in safer-sex practices.

Groups worried by change

While the American Medical Association approves of the new guidelines, believing that they will increase self-awareness, the American Civil Liberties Union�s AIDS Project worries that they will take away people�s ability to understand the magnitude of their diagnosis.

The change could also lead to people being tested without their consent in busy emergency rooms.

A national coalition of 33 organizations, including the Ohio AIDS Coalition and New York�s iconic Gay Men�s Health Crisis, issued an open letter on September 21, expressing their support for expanded testing but urging that counseling and written consent be kept.

�An expanded focus on testing without counseling and written, informed consent will put people at risk for testing without their prior knowledge or approval,� the letter said, �a clear violation of medical ethics and human rights.�

�De-linking counseling from testing is also highly problematic for many vulnerable populations,� the groups wrote. �For example, adolescents and young people, who are at particularly high risk of stigma and rejection from family and friends when disclosing their HIV status and who are often dependent on adults to access health care services and reimbursement, may not be fully prepared for the consequences of an HIV diagnosis in the absence of counseling and written, informed consent.�

�We are gravely concerned that high-risk HIV-negative individuals will fail to receive the education and support they need to remain HIV-free under testing procedures that exclude counseling and informed written consent,� the letter notes.

One leg of a three-legged stool

That sentiment is echoed by Earl Pike, executive director of the AIDS Taskforce of Greater Cleveland.

�I�m worried about losing the educational potential of a negative test result,� he said, noting that if he were counseling someone who had tested negative for the disease, he could ask them, �Is there anything I can do to help you stay negative?�

He is also worried about adding routine testing into a system where health care is expected to be dispensed in a 15-minute slot of time--HIV testing, diabetes, blood pressure, heart rate and other tests, along with treating the infection the patient came in for originally.

He also noted that, while the Bush administration originally proposed $90 million for new testing initiatives, the budget currently stands at one-third that amount.

Another problem that concerns Pike and other AIDS activists is funding for treatment.

Earlier this year, when across-the-board testing was first being floated, Pike noted that more tests would naturally increase the number of people diagnosed with HIV and needing services. However, he pointed out, the government has been unwilling to increase spending on HIV treatment, meaning that already under-funded agencies would be expected to help more people without the benefit of increased resources.

�The money has to be there,� he said.

He believes that testing is one leg of a three-legged stool. �To be stable, that stool also needs its other two legs.�

One of those is to ensure that people who test positive have access to �high quality care across the board.� The final leg is the presence and enforcement of laws and policies barring discrimination against HIV-positive people.

While people with HIV are protected under the Americans with Disabilities Act, HIV-positive employees are still fired because of their serostatus, although employers generally try to trump up other causes for their dismissals.

Pike pointed out, though, that between the two-page document and the beginning of expanded testing in the real world, there are thousands of details to be worked out, and it is in those details that the success or failure of the new guidelines lies.