Is America at the Point Where HIV Testing Should Be Routine?
For a long time doctors were subject to contradictory imperatives with regard to AIDS. On the one hand they were enjoined to treat it as they would treat any other disease, without animadversion on the way in which the patient had caught it; on the other hand they had, before testing for the presence of HIV, to seek special permission of the patient and to ensure that he or she had had counselling before the test was taken – quite unlike the testing for any other disease, syphilis for example. So AIDS was at the same time a disease like any other and also in a completely different category from all other diseases.
It cannot be said that pre-test counseling is universally popular among patients. There was an Australian clinic that famously offered the test with "guaranteed no counseling" and it did not lack for clients. For quite a number of years, however, HIV-test counselling has provided a living for the kind of people who like to hover around the edges of human catastrophe.
However, the recommendation by the United States Preventive Services Task Force (USPSTF), reported in an article in a recent edition of the New England Journal of Medicine, that henceforth the screening of adults for HIV infection should be routine will, if adopted, put paid to all such pre-test counseling. One cannot counsel scores or hundreds of millions of people.
Seven years ago the USPSTF came to a different conclusion on the question of screening for HIV, believing that the benefits were insufficient to recommend it. Since then, however, evidence has accumulated that treating people early in the course of their infection not only prolongs their life but reduces spread of the infection.
It is estimated that about 56,000 people are infected with HIV annually in the United States, while a quarter of the 1.1 million people estimated to have been infected are unaware of their infection. They constitute an unwitting risk to others; most of them will not be diagnosed until they have developed AIDS, when their prognosis will be worse than it would have been had they been diagnosed early. Forty-one per cent of those newly diagnosed with AIDS have never had an HIV test before diagnosis.
The USPSTF therefore came to the conclusion that screening the adult population was now justified, and that people should have to opt out of testing rather than opt into it. Interestingly, one of the reasons it had come to precisely the opposite conclusion previously was that it feared that those who tested HIV positive back in 2005 might suffer “rejection, abandonment, verbal abuse, and physical assault” – though from whom, exactly, the article in the NEJM does not specify. But since the results of the tests even then would presumably have been kept confidential, it could only feared that those party to the results would react in this way: that is to say doctors, nurses, and those with access to medical records.
I recall one of the most shameful scenes of my medical career, when AIDS was still a new disease. A patient in my hospital was thought possibly to have been suffering from AIDS – the diagnosis in those days was distinctly more hit-and-miss than it is now. A doctor senior to me, terrified that he might catch the disease just by proximity, refused to enter the patient’s room. I thought this a terrible dereliction of duty, the like of which I have not seen since.
One of the effects of the USPSTF is that, under the Affordable Care Act, tests will be free to those who have them; and the costs of subsequent treatment will put severe pressure on present budgetary allocations: unless, that is, the aggregate costs of early treatment are less than those of late treatment.
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