Sean Philpott: Routine Screening for HIV: A Tasking Challenge
Rumor has it that, sometime in the next few weeks, the US Preventative Services Task Force is expected to release a report recommending that HIV testing become a routine part of medical care. For a sexually active adult this means that anytime you go for a check up your doctor would be expected to screen you for the virus that causes AIDS.
If this rumor proves to be true, it would represent a sea change in current HIV screening practices. The Task Force’s current guidelines, released in 2005, recommend routine screening only for people known to be at increased risk for HIV infection or for pregnant women. However, these guidelines do not recommend routine testing of every sexually active adult.
The current Task Force recommendations also stand in stark contrast to those issued by other government agencies and public health organizations. The US Centers for Disease Control and Prevention (CDC), for example, has long called for the routinization of HIV test, noting that thousands of Americans do not even know that they are infected with HIV. Over 20% of all Americans living with HIV are unaware of their infection status. Most learn that they have HIV only after being hospitalized with an AIDS-related illness. By making testing a routine part of medical care, the CDC argues, those with HIV can be referred for care and treatment as soon as possible. Early treatment not only their own health outcomes but also reduces the likelihood that they will transmit the virus to others.
So what makes the potential change to the Task Force’s recommendations so important? First of all, there is potential political impact. Established in 1984 to provide advice to the federal government about which clinical preventative services to promote, the previously obscure Preventative Services Task Force recently leapt into the public eye with a controversial recommendation that discouraged routine screening of women under the age of 50 for breast cancer by mammography. The Task Force also received a lot of negative press for discouraging the use of the prostate-specific antigen (PSA) test to screen for prostate cancer in men. Given the lingering stigma around HIV– particularly since AIDS is still seen as a disease of gay men and drug users – any Task Force decision on routine screening for the virus is likely to engender acrimony.
Any Task Force recommendation also has a significant financial implication. Under the 2010 Affordable Care Act, public and private insurers must fully cover all preventative services that the Task Force endorses. Critics of routine testing often point to a study that estimates the cost of testing all Americans to be nearly $27 billion, with 12,000 individuals screened for every one case of HIV detected. Others have argued, however, that adding an HIV test to the blood exam done during a standard physical would cost less than $2. Moreover, the costs of routine testing would likely offset by the number of new infections prevented by getting those living with HIV into treatment. One model suggests that over 200,000 new infections could be prevented, given that the lifetime cost of HIV treatment averages nearly $350,000, provides a cost savings of $70 trillion.
For this reason alone, I personally favor the idea of routine HIV testing of all sexually active adults. Too many people in the US are unaware of their HIV status, often because they do not self-identify as belonging to an at-risk group. However, given the current social, economic and political climate, I worry whether now is the right time make HIV testing a routine part of health care.
A positive HIV diagnosis is a life-changing event. People living with HIV/AIDS in the US still face considerable discrimination, and numerous studies have shown that those who test positive for the virus are at increased risk of depression and suicidal behaviors. Many experts thus argue that there is a need for intensive counseling to assess an individual’s readiness to be screened, to prepare them deal with the psychological and social impact of a positive (and negative) test result, and to provide them with referrals to HIV treatment as necessary. It is difficult to see how harried doctors and nurse practitioners can provide this, given that most of them whom have 15 minutes or less to spend with each patient they see.
Finally, including routine testing as part of regular check-ups doesn’t mean that we will identify all (or even a majority) of the people who do not yet know they have HIV. Rates of HIV infection tend to be higher among social and economically disadvantaged groups who lack health insurance or access to routine care.
That said, let me be clear that I do consider universal testing for HIV to be important. All sexually active adults should be tested and, if positive, should seek treatment in order to preserve their health and protect their loved ones from infection. But it will take more than a pronouncement from the US Preventative Services Task Force to accomplish that, particularly in the absence of commensurate social, economic and political changes.
A public health researcher and ethicist by training, Dr. Sean Philpott is a professor of bioethics at Union Graduate College in Schenectady, New York. He is also the Chair of the US Environmental Protection Agency’s Human Studies Review Board, which reviews all research involving human participants submitted to the EPA for regulatory purposes.
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