By Dawn Wolfe Gutterman
ATLANTA – The number of people who are infected with HIV and don't know it, both nationally and in Michigan, could decrease radically under proposed government guidelines that would make testing for HIV part of every routine medical examination.
The guidelines for voluntary testing would apply to every American ages 13 to 64, according to the proposed plan by the U.S. Centers for Disease Control and Prevention.
According to the National Institutes of Health, as many as one quarter of the estimated 950,000 people in the U.S. who are infected with HIV don't even know they're ill. The Michigan Department of Community Health estimated in April of this year that 16,200 state residents are living with HIV/AIDS.
The recommendations aren't legally binding, but they influence what doctors do and what health insurance programs cover.
According to Eve Mokotoff, HIV/AIDS epidemiology manager for the Michigan Department of Community Health, the new guidelines would benefit both public health and the health of individuals who have HIV but aren't aware that they're ill.
"When people don't get tested for HIV until they're sick, their chances of remaining symptom-free and leading a healthier life decreases," she said. In addition, individuals who test positive during the routine tests will learn, "how and to keep [themselves] healthier and less infectious to others." Mokotoff, who began Michigan's AIDS surveillance program 20 years ago, was invited by the CDC to participate in formulating the proposed guidelines.
"People should be tested now that we have good treatments," she added. "This isn't 1987 anymore. There was always the question, 'What's the point of my getting diagnosed – what good is it going to do me?' Well, the good that it does you now is that you get into care, hopefully."
Mokotoff called the high number of HIV-infected people who don't know their status, "a failure of a profound proportion for our medical system. We should not be diagnosing people with HIV and AIDS simultaneously in this country in 2006; that is a failure we should be ashamed of."
Mokotoff said community-based organizations, which provide pre- and post-test counseling as well as HIV testing, will continue to play an important role under the new guidelines. For those who can't afford a regular doctor's visit, who don't want to discuss their sexual activities with their physicians or who simply want to know their HIV status, "the community-based organization is the place to go, because honestly they know more about HIV than your average, run of the mill doctor does."
The new guidelines do not require physicians to provide pre-test counseling, a provision that concerns Hank Millbourne, associate executive director of AIDS Partnership Michigan.
"One of the things that happens in pre-test counseling is you help people to look at what their behaviors are – to get them to think about what kinds of behavior they may be engaging in that may put them at risk, not only for HIV but for other sexually transmitted infections," Millbourne said. "I think pre-test counseling has tremendous advantages even for people who are testing negative because the idea is to keep them negative."
According to Mokotoff, though, "The CDC tried to put out guidelines requiring pre-test counseling for HIV in a doctor's office several years ago and they were completely ignored. We are living and operating in a medical culture where time with our clinicians is getting less and less and less and worse and worse, and if we continue to require pre-test counseling people aren't going to get their HIV test done. I think that the need to know at this point, given where we are with treatments, that the need to know outweighs the loss of [pre-test counseling] as a source of information for HIV. In an ideal world you would do them both, but … knowing your status is clearly critical."
Another potentially controversial aspect of the new guidelines is that they call on doctors to list their patients' HIV risk factors in the patients' medical records. This guideline could have troubling consequences for men who have sex with men; among other things, it is still legal in several states including Michigan to fire employees because of their sexual orientation.
Mokotoff acknowledged that this aspect of the recommendations might trouble some people. "I think that concern has existed forever and I don't think this recommendation will change that," she said. However, given that in the past HIV testing was usually only done based on a patient's symptoms or risk factors, "in the past running a test for HIV and putting that on your record would be a code word for particular behavior that people might be concerned about that perhaps a doctor didn't write in the chart."
Making HIV testing a routine part of medical visits would remove it as a potential "code word" in the patient's chart, Mokotoff said.
As for "the discussion a patient has with their clinician about what [is] put in their medical records – this doesn't change that. They still need to have that conversation," she said.
According to Mokotoff, the new guidelines will also decrease the stigma associated with HIV and AIDS.
"As long as testing has been risk-based, it's going to keep stigma going," she said. But, "I think that if clinicians [tell patients] we do your routine blood work and it includes HIV because we do this on everybody, it's accepted in a very different way. And I think it will help decrease stigma to have it routinized."
Millbourne disagreed.
"I don't think the stigma's in the hospital – I think the stigma's in the community," he said. "It may cut down on the stigma among physicians and health care workers, but I don't think it's going to touch the stigma in the community."
It's possible that more people aren't seeking out HIV testing because they assume they're already being tested when they visit their doctor. According to notes from a CDC-sponsored gathering of HIV and health care professionals provided to BTL by Mokotoff, "One representative of an urban hospital in the south said they had asked hospitalized patients if they had been tested for HIV on that admission. Ninety-five percent said yes, even though they had not. … These untested patients assumed they were HIV negative because they felt they would be told if they were positive."
"Testing people at risk for HIV is still one of the most effective tools for lowering risk behaviors and getting people who need it into treatment" said Craig Covey, CEO of Midwest AIDS Prevention Project, based in Ferndale. "We will look at the new recommendations from the CDC and cooperate with them and with the state health department to be ready to do our part."
And while Millbourne had concerns, he called the overall goal of making sure more people receive the test "laudable."
Additional reporting provided by The Associated Press.
