The Center for Disease Control estimates that over 250,000 HIV-positive Americans are unaware of their HIV status. Forty-four percent of those aware of their HIV status only discovered it after they developed symptoms. New infections could be reduced by 30 percent if all HIV-positive people knew of their status and changed their behaviors accordingly.
Drawing from research conducted over the past decade, on Sept. 22 the CDC published new HIV testing recommendations for health care providers, which aim to increase early HIV diagnosis.
Under the new guidelines, healthcare providers are recommended to screen all patients between the ages of 13 and 64, regardless of their risk. The previous guidelines limited the group to high-risk individuals and all patients in settings with a high prevalence of HIV.
Medical Director of Tufts Health Services Dr. Margaret Higham approves of the CDC's recommendations. "I fully support the new HIV testing guidelines," she said. "The old guidelines made sense at the time, but now the country needs to make HIV testing a routine part of health care."
Although the CDC report recommends testing for all patients, it emphasizes that routine testing is voluntary, and that patients can "opt out."
Higham said that she would like to see routine testing at Tufts. "HIV does not occur with high prevalence in our setting, but as the guidelines make clear, the maximum benefits will occur if everyone has HIV testing," she said. "I would love to provide HIV testing more rapidly and easily."
The new guidelines aim to address how rapidly and easily HIV testing can be done. Performing risk assessments to decide who needs testing and determining HIV prevalence are often time-consuming affairs.
The new recommendations also seek to speed up the testing process by getting rid of the required pre-testing counseling and separate written consent for the test. Instead, they advocate incorporating consent for HIV testing into consent for general medical care.
Tufts Health Services currently follows the previous CDC guidelines. This means that students must request to set up an appointment for an HIV test. Health Services provides extensive pre-test counseling, and time is also spent discussing risks for other sexually transmitted diseases.
"Often it is time well spent. But still, it would be nice to streamline this somehow," Higham said.
Higham said students would still have to pay for HIV testing under the new guidelines, but that the associated cost of $20 is low and is covered by some health insurance providers.
Tufts' Community Health Program Director Dr. Edith Balbach agreed that the new recommendations are a welcome change. She pointed out that the previous guidelines were written in the early 1990s when HIV was widely perceived as a "death sentence."
Now, at least in the United States, "HIV is considered increasingly as a long term, manageable condition," Balbach said.
"CDC is trying to reduce the stigma associated with HIV testing by making screening normal and routine," she said.
According to junior Ari Rosenbaum, however, patients can experience increased stigma as a result of routine testing.
"One of the things that gets lost in this process is the right of the individual to have agency over their own health care, free of stigma or pressure from the overseeing health organizations," he said.
"The discrimination that is imposed upon those individuals already infected could increase or perpetuate as primary health care providers become aware of the HIV-status of their patients," Rosenbaum added.
Despite his concerns, Rosenbaum acknowledged the recommendations' significance. "I think that suggesting screening for all the population that is perceived as sexually active is an important perspective change in HIV-testing," he said.
Balbach highlighted the benefits of people knowing their HIV status. "People who know they're positive will take steps to protect themselves and others, and early treatment for their condition when their T-cell count is still high will keep them healthier for longer periods of time," she said.
However, Balbach voiced her concerns about the guidelines. "I feel that the net that's been set up has a few holes in it," she said.
Balbach explained that Americans without health insurance (46.6 million, according to the 2005 U.S. Census Bureau report) generally do not go for regular health check ups, and hence may not be picked up by the "net."
She also noted the correlation of poverty to both the inability to afford health coverage and to the occurrence of HIV.
Even if they knew their HIV status, Balbach said, many without health insurance could not afford treatment.
Balbach fears that these factors might lead to a widening health disparity between those who have health coverage and those who do not. "I would have liked to know how the plan could have addressed this issue," she said, though an improvement over the previous guidelines.
Tufts students agreed, citing the fact that routing testing will likely help curb the spread of HIV.
"Routine testing will be a good idea...more people will know they have the disease and hopefully take appropriate measures to protect their partners," senior Apurvi Mehta said.
Sophomore Sarah Davis also felt that routine testing would be beneficial. "I think it is important for everyone who is sexually active to realize that they are at risk for HIV," Davis said.
Davis added that not everyone realizes their risk: "I think we all still have a tendency to think that only certain acts are dangerous, like anal sex for gay men," she said. "But other acts can transmit HIV: anytime anyone has a cut in their mouth, in small cuts in the vagina or anus, those all increase risk factors and can make even supposedly safe acts risky."
Davis said testing should be viewed as a social obligation. "Even if an individual feels they are not personally high risk, it is really important to stay up to date on testing for all STDs, out of a responsibility to a community, queer or not, and to lovers," she said.
