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U.S. Urges H.I.V. Tests for Adults and Teenagers, Published: September 22, 2006



In a major shift of policy, the federal government recommended yesterday that all teenagers and most adults have H.I.V. tests as part of routine medical care because too many Americans infected with the AIDS virus don’t know it.



Is it a good idea to remove consent forms and pretest counseling to encourage more AIDS testing?



The recommendation, by the Centers for Disease Control and Prevention, urges testing at least once for everyone aged 13 to 64 and annual tests for those with high-risk behavior.



The proposal is a sharp break from the early days of the AIDS epidemic, when the stigma of the disease and the fear of social ostracism caused many people to avoid being tested.



That led to heated debate about whether positive test results could be shared by medical and governmental authorities in their effort to contain the epidemic by reaching out to partners of those who might be infected.



Under the agency’s plan, which states can adopt or modify if they choose, patients would be advised they were being tested, but the tests would be voluntary.



So that the tests could be easily administered, however, the agency urged the removal of two major barriers that some states now have: separate signed consent forms and lengthy counseling before each test.



That would require new laws in some states, however, which could take years because some civil liberties groups and lobbyists for people with AIDS oppose the changes.



Many doctors are expected to welcome the changes.



“These recommendations are important for early diagnosis and to reduce the stigma still associated with H.I.V. testing,” said Dr. Nancy Nielsen, a board member of the American Medical Association, which endorsed the new guidelines.



Dr. Julie Gerberding, the disease control agency’s director and a doctor who treated some of the first San Francisco AIDS patients in 1981, said: “Our traditional approaches have not been successful. People who don’t know their own H.I.V. status account for 50 to 70 percent of all new infections. If they knew, they would take steps to protect themselves and their partners.”



The new guidelines, if adopted, would move the agency toward its “ultimate goals,” which Dr. Gerberding described as: no more H.I.V.-infected children, no one living for years without antiretroviral treatment and, eventually, no more new cases of the disease.



About 40,000 Americans are newly infected each year, a number that has been remaining steady. In contrast to the early days of the epidemic, which struck gay men the hardest, many of those now infected are black or Hispanic, are teenagers and were infected by heterosexual sex. The agency estimates that 250,000 Americans, a quarter of those with the disease, do not know they are infected.



Moreover, 42 percent of those who find out they are infected are tested only because they are already seriously ill — which means they have been infected for up to 10 years and may have been passing the infection on all that time, Dr. Gerberding said.



The American Academy of H.I.V. Medicine, a group for AIDS specialists, gave a qualified endorsement of the guidelines, agreeing with the need for more testing but arguing that they gave counseling short shrift.



“Counseling just naturally goes with testing, as diet does to exercise,” said Dr. Jeff Schouten, the academy’s chairman.



Some civil liberties organizations and those representing people with AIDS, while favoring more testing, have lobbied against removing signed consent forms or pretest counseling for fear that such changes will make testing less voluntary.



Some states, including New York, have laws requiring such counseling and consent forms. They were passed in the early days of the AIDS epidemic, when having the virus amounted to a death sentence, the disease’s stigma often led to denial of jobs or housing, and testing was done primarily to protect the blood supply.



Dr. Thomas R. Frieden, New York City’s health commissioner, said yesterday that he “absolutely” agreed with the new guidelines and had been lobbying the state Legislature for a law incorporating them.



A bill he supported was introduced late last year, Dr. Frieden said, but opponents kept it from coming up for a vote.



“I am optimistic that it will make it through this year,” he said.



Rose A. Saxe, a staff lawyer with the AIDS Project of the American Civil Liberties Union, said her group opposed the recommendation because it would remove the requirement for signed consent forms and pretest counseling. In settings like emergency rooms where doctors are strapped for time, Ms. Saxe said, “we’re concerned that what the C.D.C. calls routine testing will become mandatory testing.”



Patients, particularly teenagers, she said, “will be tested without an opportunity for understanding the magnitude of having a positive result.”



David Ernesto Munar, associate director of the AIDS Foundation of Chicago and a board member of the National Association of People With AIDS, said he favored more testing and faster counseling to encourage it.



“But our fear,” Dr. Munar said, “is that on the ground, the rush to get more blood samples is going to railroad right over any consent.”



Illinois, like New York, requires written consent before a test, he said.



Disease control agency experts deny that their guidelines would encourage such problems.



They oppose mandatory testing, secret testing or testing without informing patients, at least orally, that such a test will be done. They suggest that whatever general consent for routine medical care a state law requires include consent for H.I.V. testing.



Is it a good idea to remove consent forms and pretest counseling to encourage more AIDS testing?



They also want anyone who tests positive to be counseled that AIDS is a serious disease and taught where to get treatment and how to keep from infecting others.



As an example of success in a related program, Dr. Timothy Mastro, acting director of the agency’s AIDS prevention division, pointed to the agency’s guidelines to prevent infection of newborns.



The guidelines say that all pregnant women should be tested unless they refuse and that oral consent is acceptable. They also recommend tests again in late pregnancy for women who inject drugs, have sex with many men, have sex for money or live in neighborhoods where AIDS is common.



The number of babies born infected dropped to fewer than 240 a year now from 1,650 in 1991, Dr. Mastro said.



Laws for prisoners, which Dr. Mastro described as “a tricky area,” might also need revision. In some states, testing is mandatory for all prisoners. In New York, it is voluntary.



Health officials in other states appeared to welcome the new guidelines. Steve Huard, spokesman for the Hillsborough County Health Department, which includes Tampa, Fla., said: “We strongly believe in universal H.I.V. testing through anonymous and confidential testing. With the recommendations, it would be more widespread. It would go out to private physicians and we should see infection rates going down.”



Some states with few AIDS patients, like Wyoming, may be reluctant to adopt the guidelines on the ground that routine H.I.V. tests would be unnecessarily burdensome for doctors and patients.



To compensate for that, the guidelines suggest that routine tests might not be required in areas where fewer than 1 in 1,000 people test positive. But health care practitioners are not very good at guessing what rate will be found among their patients, said Dr. Bernard Branson, the C.D.C.’s associate director for laboratory diagnostics, so there should first be a period of routine testing.



The wholesale cost is about $1 for each test run in batches and about $8 for rapid tests done individually. Each positive test would require a second confirmation test and then counseling, which would raise the cost to about $80, Dr. Branson said.



That is far cheaper than many other routine screening tests like colonoscopies or mammograms, and Dr. Branson said most such tests were paid for by insurers because it was usually cheaper to treat diseases when they were caught early.