The U.S. Preventive Services Task Force formally published its recommendation for routine HIV testing for all individuals age 15 to 65 in the Annals of Internal Medicine this week. An editorial and patient materials are all available free to anyone with an Internet connection. Many people who work in HIV hoped that this would finally move HIV into mainstream medicine. With a U.S. Preventive Services Task Force Recommendation, patients don’t need to ask for the test, it would become a routine blood test like many others, stigma would be reduced, and insurance would likely cover it. The evidence backs it. However, within 24 hours of the Task Force Recommendation going up online, the American Academy of Family Physicians questioned age 15 as the logical starting point, instead urging that testing begin at age 18. This is just some of the resistance that the medical community is putting forward now.
Several months ago, I spoke with Roger Chou, MD, MPH, associate professor of internal medicine at Oregon Health and Science University, Portland, Oregon, who headed the evidence review for the U.S. Preventive Services Task Force. “About 25% of people who have HIV are not aware of it,” Chou said. “They have no identifiable risk factors.”
Other reasons why data to back routine HIV testing are in, include that “the screening test is highly accurate, we have direct evidence from randomized controlled trials that we can reduce the risk of transmission by 90%, and that you can’t trust what your patient says, or that patients don’t always think that they are at risk,” said Chou.
Disclosure a Huge Problem
“If we learned anything about the announcement earlier this week that Jason Collins is gay, it ought to be that you can’t just look at someone and put them into a risk category,” said Donna Futterman, MD, Director of the Adolescent AIDS Program, and Professor of Clinical Pediatrics, Children’s Hospital of Montefiore, Albert Einstein College of Medicine, Bronx, New York. “Most people who are gay won’t share that with providers that they are gay.” Notably, two days after Collins’ announcement, his former fiancé went on television to say that she had no clue that Collins was gay. This is not to imply anything about Collins’ HIV status whatsoever.
“People simply don’t volunteer that they are having unprotected male-to-male sex, taking IV drugs with dirty needles, and “we really can’t define what high-risk behavior is,” Chou explained. Therefore, targeted screening to so-called high-risk groups misses the boat.
“Step one of the HIV Treatment cascade – is finding and testing people with HIV,” Futterman told me. “It is the step that involves the non-HIV care system. We need to engage the primary care providers and system in routinely offering testing so as to find those with HIV who don’t know their status.”
Judy Levison, MD, associate professor of obstetrics and gynecology, Baylor College of Medicine, Houston, Texas, works with women with HIV who are pregnant. The USPSTF and many health authorities previously recommended HIV testing for all pregnant women. Levison sees enormous public health value in the medical community adding HIV testing to regular screening panels that patients have done when they see their primary care provider.
Although we all like to think we know the sexual patterns of people we are sleeping with, Levison says that she sees plenty of pregnant women who don’t fit the stereotype for HIV. These are women who have been in longlasting marriages, who get the surprise of their lives when they test positive for HIV. “Sometimes it is a married woman who has no idea her husband is having unprotected sex with men,” she said. “Or someone who slipped up once a long time ago with someone she thought she knew.” Levison remembered a patient quote in the book Mortal Secrets: Truth and Lies in the Age of AIDS, by Richard Klitzman and Ronald Bayer: “What was my crime? I loved someone.”
With antiretroviral therapies proving that HIV can be treated just like many other chronic diseases, enabling people to have a full life, have healthy babies, and see them grow up, Levison sees enormous benefits with HIV testing expanding to adults and teens. “The successes of universal testing in pregnancy — and discovering many women not known to have risk factors do have HIV–is central to the recommendation to test all adults. Currently, those who do not know they have HIV are responsible for a large proportion of newly transmitted infections.”
Michael Saag, MD, Director of the Center for AIDS Research, University of Alabama Birmingham, amplifies this: “The bottom line: Anyone who is sexually active, or has even thought about being sexually active should be tested for HIV at least once…and more often if they remain active, especially with multiple partners over time.” As for an age cut-off, he added: “I don’t know of a specific age cut-off that applies in either direction that would apply to everyone. Therefore, I think age distinctions are a bit of a distraction. This is about function and activity, not age.”
Medical Community Views HIV Differently
When we learn that large proportions of Americans have hypertension, diabetes, or high cholesterol, and don’t know it, what do we do? We view it as a missed opportunity, and mount large campaigns to get people tested, followed, and into care to bring their blood pressure down, and keep it down. Not so for HIV.
“It’s been a very difficult sell for providers,” Futterman told me. Providers resist thinking that their patients could possibly have HIV because they don’t obviously fit into the targeted risk groups and they don’t envisage much yield in their practice. What Futterman thinks is urgently needed is to add HIV testing to routine blood screening panels. But HIV testing is segregated, a “holdover from the early days when pre- and post-test counseling were in place.” Although there were good historical reasons for splintering it aside – patient protections and discrimination especially – that no longer justifies keeping it separate.
“Practice change won’t happen unless we work on physician buy-in, implementation, and evaluation,” said Futterman. What she would like to see is for the test to become streamlined, have HIV testing incorporated as a measure of quality for the Joint Commission on Accreditation of Health Care Organizations. “We need to get rid of the special laws related to consent,” she said. “If it is complicated to do it, it won’t be done.”