The Case for Expanding Human Immunodeficiency Virus Testing
Judith Feinberg, MD
University of Cincinnati, Ohio
Address correspondence to Judith Feinberg, MD, University of Cincinnati, Eden Ave and Sabin Way, Cincinnati, OH 45267-0405 (e-mail: judith.feinberg@uc.edu)
Despite these early recommendations, only 3 studies have been published assessing the utility of offering routine inpatient HIV testing. In this issue of Mayo Clinic Proceedings, Greenwald et al3 report a retrospective cohort study that evaluates 81 inpatients at a major hospital in Boston, Mass, who tested HIV positive between 1999 and 2003 and compares them to both the same number of inpatients who tested negative and to HIV-infected persons tested in an ambulatory care setting. Initially, testing was offered to inpatients referred by their physician, but by 2001 testing was expanded to all those admitted to the adult medical service. Studies have shown that many infected individuals do not undergo testing until late in the course of their HIV disease, when serious illness or an AIDS-defining condition requiring hospitalization has ensued; in a prior report, 41% of patients with newly diagnosed HIV were diagnosed as having AIDS within 1 year of testing positive.4 In the current study,3 79% of those who tested positive had a diagnosis of AIDS made concurrently on the basis of a clinical condition or a CD4 cell count lower than 200 cells/mm3. In a multivariate analysis, Greenwald et al demonstrate that the inpatients identified as having HIV infection had significantly lower CD4 cell counts and higher HIV viral loads than those whose diagnosis was made on an outpatient basis. As shown in their Figure 2, CD4 cell counts differed markedly among 3 discharge diagnosis categories—HIV related, possibly related, and unrelated—with the lowest counts in patients who had HIV-related diagnoses. Although some of the conditions categorized as “unrelated,” (eg, diarrhea, non-Hodgkin lymphoma, soft tissue infection, and viral syndrome) may have led to a small number of diagnoses that might have been classified as related or possibly related,5,6 it is unlikely that the ultimate outcome of this analysis would be changed given the magnitude of the differences between the related and unrelated groups.
In 2003, the CDC unveiled a new plan called “Advancing HIV Prevention: New Strategies for a Changing Epidemic.”11 This campaign is focused on reducing barriers to the early diagnosis of HIV, increasing access to care, and providing ongoing prevention efforts to those already infected. It has 4 key initiatives, 3 of which involve testing more broadly for HIV infection: (1) incorporate HIV testing as part of routine medical care; (2) with the use of a new rapid HIV test, implement new models for HIV testing outside traditional medical settings, such as drug treatment programs, homeless shelters, and prisons; (3) prevent new infections by focusing on behavior changes for individuals already infected and their partners (“Prevention for Positives”), and (4) further decrease perinatal transmission by expanding testing for all pregnant women, including the use of a rapid test during labor and delivery or immediately postpartum. This focus on expanding testing; getting newly diagnosed individuals to obtain medical care; ensuring access to antiretroviral therapy to control patients’ viral loads, both to maintain their health and to reduce the likelihood of horizontal and vertical infection; and encouraging behavior change in seropositive persons all make great sense as public health policy. In an unpublished CDC study of 7236 newly diagnosed persons, the most frequent reason for seeking testing was illness (42%); only 10% of the HIV-positive men and 17% of the women were tested primarily because their health care professional offered or recommended testing.11 By involving physicians and other health care professionals more intensively in testing and prevention efforts, it is hoped that the health care professional-patient bond will have a greater influence on stemming the epidemic than do the currently separate HIV testing and care structures.
Moreover, there are worrisome growing racial and ethnic disparities among persons diagnosed with HIV infection,12 with the number of cases and diagnosis rates in black persons far exceeding those in white persons. We may not make adequate headway in stemming the rate of new infections in these groups until testing is more widespread and routine. In minority communities, the stigma attached to HIV infection is tremendous, as the “down low” phenomenon illustrates. This refers to black men who are bisexual but unwilling to share that fact with their female partners, who are unsuspecting of their potential exposure to HIV and other sexually transmitted diseases. As expected, the idea of “normalizing” testing—that is, including HIV testing as a routine part of an individual’s overall consent to receive care—for all persons between 13 and 64 years of age13 has raised some opposition. If a person does not want to be tested for HIV, he or she will have to “opt out,” that is, refuse the test, a distinct departure from the established policy of “opting in,” in which the caregiver or the patient has to specifically request and consent to an HIV test, whether anonymously or as a part of routine care. To enhance the feasibility of including testing as part of routine care, the CDC has recommended that clinicians dispense with pretest counseling, a cornerstone of the former recommendations. In this manner, the CDC hopes that the large number of persons unaware of their positive HIV status will be identified, referred for care, given antiretroviral therapy as appropriate, and educated about the risks of infecting others. This hopefully will further reduce transmission to others as a result of controlling viral replication and encouraging the use of safe-sex practices.
