AIDS at 25

In the United States, approximately a third of those who are HIV-positive don't even realize it. Worldwide, that number can be much higher. Because of this, and because those who don't know their HIV status can play a large role in continuing to spread the virus, in recent years, there has been an increased push for more universal HIV testing, in order to decrease this percentage unaware of their HIV status, and theoretically, reduce spread of the virus. But is this a good idea, and how exactly would and should it be accomplished? This was the topic of discussion at a session titled HIV Testing In the Era of Treatment Scale Up (video at the link).

This is an area of much contention; I'll highlight some of the major issues after the cut.

Currently, the testing paradigm in most areas is patient-instituted, and involves the three C's: consent, confidentiality, and counseling (generally before and after the test). If HIV testing were increased, a concern is that the quality of counseling could decrease, due to the lesser availability of trained professionals to discuss the implications of the test with patients. This could leave individuals whose test came back positive for HIV floundering, unsure what to do next, how to receive treatment or protect their loved ones from infection (or discuss that possibility with them), and unversed in dealing with the stigma that may follow a diagnosis of infection with HIV.

For these reasons, it's unlikely that any kind of universal testing will occur anytime soon. However, there is a push to move from testing that's initiated by the patient (actively requesting to be screened) to testing that's initiated by the provider (suggesting to their patients that they be tested for HIV). This proactive approach on the part of health care personnel could raise awareness of the importance of being tested while maintaining the critical issue of counseling and discussion of results. (I'll note that some providers to this already, but it's not the standard).

If more routine testing does eventually occur, there are a number of other issues that come along with it. First, should it be universal testing (such as, everyone gets screened at a physician visit as a matter of course) or a routine offer (as it suggests, that everyone is offered access to such a test). If it's routine testing, can one opt out? Even if the option for opting out is put in place, will the patient feel like they're really able to use it, or will the imbalance in power between the patient and health care provider make this too difficult? Additionally, in some countries (such as Botswana), it's still legal to discriminate against HIV-positive individuals when it comes to employment. Obviously, testing positive there has the potential to have a much greater impact on one's life and livelihood than it does in countries where it's illegal to discriminate in this manner.

So, the issues regarding this type of testing are far from cut-and-dry. However, there seemed to be general agreement that the status quo--patient-initiated testing--simply isn't working well enough. Perhaps more universal testing would reduce some of the stigma, since as things are now, just asking for the test is essentially seen as an acknowledgement that you've done something society deems "immoral", such as having sex or using drugs.

Finally, though, even with the routine offer model, that only applies to people who are already at the clinic, hospital, or their private physician. It does nothing to reach those who don't come in for medical care, even though they may be carrying the virus. That's an even more difficult population to reach, and any effort to curb the spread of HIV based on increased awareness of HIV status followed by behavioral modification must also incorporate active promotion of testing outside of medical facilities. It's a tall order, but one we'll likely hear much more about in the coming years.

Image from http://www.cnn.com/HEALTH/9605/14/nfm/hiv.home.test/testing.lg.jpg