Published: February 21, 2013
Routine HIV screening – a proposed recommendation by the U.S. Preventive Services Task Force — is likely to remove important barriers that leave about 25% of HIV-positive people unaware they have the virus.
But it would be only the first step in getting all HIV-positive people in the U.S. into care.
In two separate Perspective articles, published online in the New England Journal of Medicine, experts argue that the proposed recommendation has the potential for some far-reaching consequences, including getting more people into care, improving their health, and slowing the rate of transmission of HIV.
The task force’s view in 2005, when it last made a recommendation on HIV screening, was that evidence was insufficient to support it as a routine practice. A year later, the CDC took the opposite tack, urging routine testing in almost all health care settings and for almost all adults.
In 2010, the task force reopened the issue, asking the Pacific Northwest Evidence-based Practice Center to review the available evidence.
The center’s findings, presented to the task force last March, led to the current draft recommendation, which says there is “high certainty” that routine screening would have both public and individual health benefits.
The task force is suggesting an A grade for the recommendation, which would mean that most people under 65 would have access to HIV testing without an out-of-pocket cost, noted Erika Martin, PhD, of the State University of New York in Albany, and Bruce Schackman, PhD, of Weill Cornell Medical College in New York City.
It would also mean that clinicians would no longer have to consider risk factors or local HIV prevalence before offering the test, they added. Taken together, those factors will transform HIV testing into a routine procedure, they argued.
The recommendation, if adopted, will end what has been a long-running debate on the appropriate scope of HIV testing, argued Ronald Bayer, PhD, and Gerald Oppenheimer, PhD, both of Columbia University’s Mailman School of Public Health in New York City.
But the central question, they wrote, is whether routine screening at no cost will “substantially alter the persistent inability” to identify the millions of Americans who don’t know they have HIV infection.
Failure, they concluded, will have “measurable clinical consequences” for patients who do not get timely care as well as public health consequences, including failing to reduce HIV transmission.
Success, on the other hand, will have other – mainly financial — consequences, argued Martin and Schackman, as more people line up for care and treatment.
The Affordable Care Act should alleviate some of the concern about paying for treatment, they noted, but “health care reform will not fix all gaps in health care delivery.”
For instance, they wrote, coverage is likely to vary among states, which could affect quality of care. As well, some people – such as immigrants or those who have difficulty with paperwork and eligibility requirements – may fall through the cracks.
The rationale for the task force draft recommendation, they noted, is that routine testing will lead to a “substantial” benefit.
“In the case of HIV screening,” they concluded, “that benefit can be achieved only if people identified as HIV-infected are effectively linked to and retained in HIV care and are supported in adhering to an effective antiretroviral regimen.”
tim barrus responds —
This is the first piece I have read about the USPSTF pushing for universal testing that even so much as mentions financial considerations to the individual being tested. It never gets discussed. I am glad to see it included here. I have worked in HIV/AIDS for thirty years. Today, I work with adolescent boys, and we have FAILED them. They have not been reached. The sex education these boys are exposed to is pathetic, and the high school phys ed teacher standing by the blackboard with a pointer is pathetic, too. The CDC has put all its marbles into the push for testing, and it has been effective, but only in that more people know they are infected. There has been virtually no equivalent emphasis put on getting the infected and newly aware they have been exposed to the virus, treatment. To test people and to not consequently have treatment for them is patently, morally, bankrupt, and moral bankruptcy is just the beginning. Medical insurance companies fight having to pay for HIV as if it were a world war. You CANNOT bring testing and treatment into the paradigm without also bringing COST into the picture because BIG PHARMA is the most greedy and immoral player in this deadly bag of tricks. Their intransigent price structures where the cost is only going up and up and up can be directly and accurately compared to genocide. HISTORY will have the final say here, and the future is going to wonder what in the world we were doing, and not doing. It will be a pox on ALL our houses. Today, the average price of one HIV pill is eighty dollars. By 2014, that pill will cost $100.00 and Big Pharma is immune to any consequences whatsoever. The CDC has worked tirelessly to impose its agenda. Its priority is universal testing. That is where it has put its money. We push testing and pretend that Obamacare will tackle treatment. It won’t. It doesn’t. And it never will. The bottom line is that no one wants to pay for it. THERE ARE WAITING LISTS FOR PEOPLE TO GET MEDS. We are quite willing to tell people they are infected, and then we turn around and run when it comes to treating them. The lack of accountability is appalling, and that includes the CDC. I sit in on panels the CDC sponsors, and it’s a rhetorical chant. Testing, testing, testing. But not a WORD about treatment. Treatment is BAD to say, and if you say it, you can lose your job. The NGOs are worse than the CDC. I talk with these people every day, and they all whine: “But we’re trying.” You are not trying hard enough. To pretend that testing is the answer, and that treatment is politically incorrect to prioritize is disgustingly absurd. The very term — AIDS-free generation — is a slogan in a world of them. It’s meaningless. It isn’t even close to being in our grasp, and anyone who thinks it is, does not understand the virulence of HIV. I have articulated these ideas to entire association conferences of HIV social workers, and during my speaking gigs people have gotten up and thrown their chairs against the hotel wall. They don’t want to hear it. They want HOPE, and if you cannot bring it to them, the reaction is explosive. So we bring them testing like it’s a placebo. The CDC is beyond irresponsible. It just gets thicker and thicker. What are we going to do in this AIDS-free generation with the undocumented adolescent who has been trafficked to do sex work on the streets of Los Angeles, and has no access to any services whatsoever, and who winds up being busted, and put on the bus back to Mexico, and given directions to the only AIDS hospice in Tijuana that can’t even afford to feed people who walk in the door. What about HIM. I have changed my position with these boys. I am no longer willing to even talk about testing. Just because people are being tested does NOT mean that an adolescent out there doing sex work for pimps is going to or even can change his or her behavior. This is a landscape where even social service agencies cannot admit that males do sex work as well as females. The 14-year-old boy doing survival sex is invisible to you. Testing, testing, testing. It’s a stupid rant. Until you are ready to bite the bullet and TREAT these people, HIV will be with us forever. Now, when I counsel the boys I work with, I do NOT say, and I cannot be compelled to say: just get tested. I have joined the rant, and I cannot do it one more time. I’m done. I am telling them don’t get tested until we all have access to treatment. Testing is a rabbit hole you can stick your deafness down into if you want, but that will not change the fact that behind the looking glass the word TREATMENT must begin to be articulated one step beyond — treatment for who. Treatment for everyone infected is just the reality. It’s politically incorrect to say any of this. The gay community doesn’t want to hear it, and either does the CDC. The World Bank isn’t exactly clicking its heels at the idea either. Example: USAIDS does video outreach to adolescents, but that outreach has to be “child-friendly” for it to actually get used. What is “child friendly?” No one knows. Exactly how does a message aimed at adolescent behavior sophomorically become rendered “child-friendly.” And we sit around and weep that we do not reach teenagers whose infection rates are going up. How many teenage boys do you know who tune into child-friendly websites at the CDC. It doesn’t matter. What people want to hear is irrelevant. Testing is only one tentacle on a very complex organism that has outsmarted us every step of the way. Leaning on the chantra of testing might look good, but it’s mean, and it does not take into account the real complexity of human behavior, and if you think people are going to change their behavior just because they’ve been tested, you, and the suits like you, are now the problem. We have FAILED the children I work with, and there is no end in sight for HIV because we FAIL to change OUR OWN behavior by historically falling for our own rhetoric about how miraculous and powerful the next pill will be. Until you are willing to actually swallow the pill of how human beings actually behave, HIV will do what it always does. It will win. Your waiting lists say everything that needs being said.