San Francisco Adopts CDC Recommendation to Not Require HIV Testing Consent & Counseling
"City health agencies move to streamline HIV testing
San Francisco drops counseling requirement"
- Erin Allday, SF Chronicle Staff Writer
Thursday, May 18, 2006
San Francisco's public medical clinics and hospitals will no longer require written consent and counseling sessions before HIV tests, and public health officials say they hope the easier, less time-consuming process will prompt more people to get tested.
The shift in policy, which took effect Tuesday, follows a similar proposal from the Centers for Disease Control in March, as the health care industry grapples with estimates that more than 20 percent of those infected with HIV don't know it -- and continue to spread the disease.
San Francisco is the first city in the country to adopt the new policy, under which people will have to give verbal, not written, permission for testing. Pretesting counseling will still be offered to those who want it, but it will no longer be mandatory, said Dr. Jeffrey Klausner, director of STD Prevention and Control for the San Francisco Department of Public Health.
Last year, 20,000 people were tested for HIV in San Francisco, and 440 of them tested positive, Klausner said.
"When I reviewed testing records earlier this year I was shocked to see a substantial proportion of people were not testing for bureaucratic reasons," Klausner said. "In medical practice, people get screened and tested for serious conditions all the time. People get mammograms, they get biopsies, these can be done without these bureaucratic hurdles. The several layers of paperwork, the required counseling for HIV testing, they were actually a barrier."
For decades, medical facilities have required written consent and counseling for HIV testing because AIDS was such a deadly disease and there was a "substantial stigma" associated with it, Klausner said.
But with new treatments available and heightened public awareness of AIDS, the strict pretesting process had become outdated and overly formal, he said. Public health officials worried that the extra precautions -- along with the wait time that required 20-minute counseling sessions -- were discouraging people from getting tested.
Klausner said San Francisco's public health department began dismantling its pretesting counseling program last summer, when the city removed funding for counseling positions at public clinics and hospitals. Since then, the medical providers actually conducting the tests have been providing counseling.
Several AIDS organizations have expressed concerns about the CDC proposal, which is still being discussed, suggesting that policies like San Francisco's could threaten patient privacy, although Klausner said that HIV testing will meet the same strict patient confidentiality rules.
Steven Tierney, deputy executive director of the San Francisco AIDS Foundation, said he supports programs that will encourage more people to get tested, but he doesn't want the testing process to be "over-simplified" to the point that people aren't making informed decisions based on conversations with a counselor or their medical provider.
"Anything that makes it easier to get tested is a good thing, but we believe folks have a right to full, informed consent," Tierney said.
CDC to recommend HIV test for most Americans
By Greg Barr
The Galveston Daily News
Published May 21, 2006
More than 1 million Americans already live with HIV infection, and more than 40,000 more are exposed to the virus each year.
But according to the Centers for Disease Control & Prevention, most new HIV infections in the country are transmitted by the 25 percent of those carrying the virus who have no idea, or don't want to know, they are infected.
CDC officials suggest that is the country's biggest problem in fighting the spread of the virus. So the national health agency has come up with a solution.
In a position paper to be published this summer, the CDC will recommend that every person in this country between the ages of 13 and 64 should voluntarily have an HIV test as part of a routine blood screening, with no need for separate consent.
"Current HIV testing recommendations call for routine testing for those at high risk ... however this process is not leading to adequate diagnosis of infection," said CDC spokesperson Tammy Nunnally.
"When people learn they are infected, they take steps to protect their (sexual) partners. Knowledge of status can also mean easier access to treatment that results in a longer, healthier lifespan."
Nunnally said that, ideally, every American would be tested at least once, but noted that it would still be possible for the patient to decline the test.
In its recommendations, the CDC will suggest that repeat HIV testing would only be for high-risk individuals such as intravenous drug users, men who have sex with men or the sex partners of HIV-positive people. But it will also recommend repeat testing for those whose sex partner has had a new, or more than one, sex partner in the past three months.
Finally, the CDC wants to do away with what it believes is a barrier to HIV testing: the required 45-minute pre-test counseling session used in most states, including Texas, when a person requests an HIV test.
"Counseling services should be focused on those who test positive," said Nunnally. "The purpose of these changes are to eliminate the complexities around HIV testing and reduce the stigma that still surrounds testing and diagnoses."
Thousands of HIV tests are done annually in laboratories around the state. At the University of Texas Medical Branch labs alone, 66,985 HIV antibody tests were performed in fiscal year 2005 - including 43,960 for prisoners under a contract with the Texas Department of Criminal Justice system.
Among 23,021 nonprisoners tested by the medical branch last year, 299 were positive - 1.3 percent, according to the university.
All women preparing to give birth at a medical branch hospital are tested. The CDC's Nunnally said that routine testing of pregnant women has led to the country's "remarkable success" in declining rates for mother-to-child HIV transmission. In the mid-1990s, some 2,000 HIV-infected children were born annually, but that number has declined to a little more than 300 a year in recent years.
"HIV testing is part of general care for pregnant women, without a separate, specific consent form," she said. "We hope to extend that success to other adults."
Last year, Galveston County Health District medical personnel saw 1,439 people at clinics in Galveston, Brazoria and Chambers counties being screened for HIV. The blood samples were sent to state labs in Austin for testing.
"We welcome any action that allows people to get a better understanding of their health. If someone is not aware of their status, then learning (about being HIV positive) is important for them and the community," said health district spokesman Kurt Koopman, when asked to comment on the broad CDC testing proposal.
William O'Brien, a medical branch professor and physician who treats AIDS patients - also a leading research expert - agrees that the CDC's proposed approach is a good one and that the lengthy pre-test counseling is a barrier to testing.
"The CDC is trying to tackle the problem of all these undetected HIV infections and make it easier for people to be tested. This is a good way to get the testing done," he said.
Still, social workers dealing with AIDS patients, while agreeing with the CDC proposal, say existing social taboos about HIV/AIDS are a barrier to any testing.
"A lot of the female clients we see had a positive test only because of the testing done for pregnant women," said Georgia Nelson, director of operations at the AIDS Coalition of Coastal Texas, which provides social services and other support to those living with HIV/AIDS.
"There is still that stigma, and people don't want others to know they are infected, and more so with women than men. Like with alcoholism and substance abuse, women seem generally more ashamed to talk about (testing positive)."
A general lack of access to health care for many people, including the uninsured, also is a barrier to HIV testing, health care workers said.
HIV screening is unsettling? It should be routine.
May 20, 2006Houston Chronicle
REGULAR news of breaches of computerized personal information is bound to make the public nervous about a federal plan that would make HIV tests part of routine doctor's visits. But the good this would do is so far-reaching, with fixes to legitimate concerns about privacy, the policy should be encouraged.
At least one quarter-million Americans are infected with AIDS but don't know it. Undiagnosed, they are the main conduit for the disease's spread. With treatment, they can manage HIV and enjoy a good quality of life.
Ideally, treatment must start before symptoms surface. Medicine is less effective in patients weakened by AIDS, and they suffer more side effects.
That's why the U.S. Centers for Disease Control is recommending making HIV testing part of routine health care. The proposals would set the standard for best practices.
Under the draft guidelines, doctors would offer HIV tests to Americans between 13 and 64. Not all patients would be screened yearly. High-risk patients, including health care workers, would be screened annually; others, every few years.
The big guns of AIDS treatment, including the American Medical Association and the American Academy of of HIV Medicine, enthusiastically support CDC's stated goal of increasing testing and erasing the stigma fueled by HIV's current detection and treatment routines.
"This is an idea whose time has come," says Dr. Judith Feinberg, the University of Cincinatti's director of HIV research. "Two-thirds of those who know they have HIV will be more responsible about protected sex. Most people don't want to give this disease to someone else."
Houston physician Karen Hill also strongly backs the guidelines and says she screens her patients routinely now. "I think you have to have a written consent form," Hill notes. "There is still such a stigma attached, patients have a right to say no."
Destigmatizing the disease is one of the objectives of across-the-board screening. Rather than singling some patients out, routine tests would treat AIDS like any other ailment.
But patient advocates, such as the American Academy of HIV Medicine, rightly worry that many insurers, employers and citizens lack this mindset. So the CDC should craft and thoroughly detail confidentiality protocols for HIV tests in its final plan. Contrary to its draft proposal, the agency also ought to urge that patients give written consent. And professional groups will have to train doctors thoroughly on patient care and screening.
Special attention should go to urging tests for patients who are certain they don't need them. "I've taken care of plenty of women who are married, and monogamous, whose only risk was their husband," AIDS specialist Feinberg points out. "That's the conundrum - you can't guess what your risk is. People aren't very truthful about their sex lives."
San Francisco makes it easier to test people for HIV
SAN FRANCISCO - Public medical clinics run by the city will no longer require written consent and counseling sessions before testing people for HIV in a bid to increase the number of people screened for the virus, officials said Wednesday.
It's a dramatic policy shift for a city at the forefront of the AIDS fight and it is the first known entity in the United States to formally loosen consent and counseling requirements. The new policy was implemented Tuesday in the city clinics and two hospitals that test patients. Last year, 240 people tested positive out of the 6,000 tested in San Francisco.
The Centers for Disease Control and Prevention is contemplating making similar recommendations, as well as proposing that most healthy patients get tested during routine physical exams.
The idea is to expand testing to find as many as 250,000 of the 1 million Americans with HIV who don't know they are infected and are most responsible for the spread of the virus.
San Francisco doctors are required to get only verbal patient permission for testing, a move city officials say will increase the number of people tested who aren't now screened because of problems with paperwork and burdensome bureaucracy.
"Once again, San Francisco is taking the lead," said Dr. Jeffrey Klausner, director of the city's sexually transmitted disease prevention. "We hope others follow this common sense approach."
Klausner said several other private hospitals in San Francisco are considering similar policy changes.
But many AIDS activists and other critics fear the changes could lead to patient privacy abuses and deter some from seeking treatment if they test positive.
Doctors at the city's General Hospital would still be required to get patients' permission verbally, but activists argue that's not enough and they continue to advocate for written consent and prescreening counseling.
"Unfortunately, HIV follows women of color and HIV follows poverty," said Diana Bruce of the Washington-based AIDS Alliance for Children, Youth & Families, which is concerned with testing pregnant women and newborns. "This population needs testing that is culturally competent, that builds their trust and that they have been properly informed in writing."
Bruce said doing away with the current testing system will increase the chances that patients testing positive for HIV won't seek treatment.
The AIDS Alliance submitted formal comments opposing the CDC's proposal to do away with written consent and counseling in March and also signed a letter along with 51 other groups protesting the proposed changes.
"We still believe pretest counseling is important, but it shouldn't be mandated," Klausner said.
Others, though, argued that streamlining the testing process will encourage more patients to get tested for HIV.
"While many counseling and consent procedures make sense to providers, they may be viewed by high-risk individuals as burdens," Dana Van Gorder of the San Francisco AIDS Foundation said in an e-mail. "If that is the case, they should be carefully reconsidered. SFGH has provided model care for HIV throughout the epidemic and I trust them to making good decisions about these changes."
The American Medical Association supports the CDC's proposed changes, which would roll HIV testing into routine physical exams. Nearly half of new HIV infections are discovered when doctors are trying to diagnose an illness in a patient who has come for care, the CDC said.