HIV Testing Roundup, and a Brief Rant

June 29, 2012

Paul E. Sax, M.D.

Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.

I've written so many times about HIV testing that a complete list of the headlines fills two full web pages.

But since the last entry on the topic was more than a month ago, one might think I've lost interest in the topic.


Three items on the HIV Testing radar, two national, one local.

First, for a classic good news/bad news report, read these latest data from CDC on previous HIV testing among newly diagnosed people with HIV in the United States. Among the highlights/lowlights:

  • Good news: 60% of more than 50,000 newly diagnosed individuals reported having a previous negative test, many within the previous couple of years so that their HIV was diagnosed early.
  • Prior negative testing was correlated with factors associated with access to care and high awareness of HIV risk: whites, individuals aged 13 to 29, and males reporting male-to-male sexual contact as their sole risk factor.
  • Bad news: blacks, those aged ≥50, heterosexual contact as the sole risk factor, and males reporting injection-drug use were least likely to have a prior negative HIV test -- and also far more likely to progress to AIDS at or shortly after diagnosis.

Since people with no history of negative tests are at risk for being diagnosed later in the course of the disease, it's got to become easier for them to get tested.


Second, could rapid HIV testing in pharmacies be part of the solution?

This sounds like a great initiative, as there is little doubt it's easier for many people to go to their pharmacies than their health care providers. I'll be particularly interested to see how this is implemented on a practical level, including feasibility, cost, acceptance rate, and most importantly, how people with positive tests get linked to care.

Third, we're only about a month away from when it becomes legal in Massachusetts to obtain an HIV test without written informed consent -- law signed in April, "official" July 31. (We'll be the last state to drop the requirement, for the record.) It's not an "opt out" policy -- verbal consent is still required -- but it's substantial progress nonetheless.

All good, right? Not so fast.

The privacy part of the HIV testing law -- which states that HIV testing results cannot be disclosed without a patient's written consent -- has not changed. Some (I hope a minority) have interpreted this to mean that written consent is still required before the test result can be reported by the lab -- even if that means simply putting the result into the patient's medical record (a record already protected by HIPAA). To quote/paraphrase an email forwarded to me from another institution:

... although the law now permits oral consent, we must still obtain written consent to share the test or results with any provider -- meaning we still need written consent to include this information in the medical record.

It goes without saying -- but I'll say it anyway -- that this bass ackwords interpretation obviously leaves us back where we were before the law changed. Thank goodness it's not an interpretation shared by all institutions and practices.

And, for the record, it's an intepretation that is utterly at odds with the intent of the change in the law, which was to expand HIV testing by removing written consent -- so that people with this potentially fatal infection can access lifesaving treatment and stop spreading the virus to others.

So glad I didn't go to law school. I'd spend hours a day with smoke coming out of my ears.

Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.

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This article was provided by NEJM Journal Watch. NEJM Journal Watch is a publication of the Massachusetts Medical Society.

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