July 12, 2006 -- As an HIV prevention counselor, Sharlene Miles knows a thing or two about slowing the spread of HIV and AIDS.
Still, she was one of hundreds of Washington, D.C., residents waiting in line recently to get a free rapid HIV test. The attendees were there to help kick off Washington's new push to encourage doctors to routinely screen everyone between the ages of 14 and 84 for the virus that causes AIDS.
Her test came back negative, and Miles wasn't surprised. She said she doesn't practice any of the behaviors that put people most at risk. However, she did say knowing your status -- whether you are HIV positive or negative -- is important.
Along with Washington's new screening program, the national Centers for Disease Control and Prevention is expected to release similar guidelines this summer that would expand HIV screening to all adults in the United States
If this happens, it means that just about anybody over the age of 13 could be asked by their doctor, "Would you like an HIV test?"
In Washington, which has one of the highest rates of new AIDS cases in the country, the capital's department of health has encouraged primary care providers, community health clinics and emergency departments to routinely screen patients for HIV. It is the first location to do so, according to Dr. Gregg Pane, the department's director.
'Almost Criminal' to Not Test
But there's benefits to a nationwide program too, experts said. At least 25 percent of Americans infected with HIV are unaware of their status, according to the CDC.
Unlike the early days of the virus in the 1980s, HIV testing is today more accurate, and the disease itself can be treated as a chronic disease, meaning people can live a normal life span, said Dr. Michael Saag, the director of the University of Alabama's Center for AIDS Research in Birmingham.
"Today, in my mind, it would be almost criminal to not test more widely for HIV. ... The reason people are dying today [from HIV/AIDS] is that they are diagnosed late. The best thing we can do is increase the amount of screening," said Saag, who explained that patients who are diagnosed early have stronger immune systems and the possibility of living longer, healthier lives compared with patients diagnosed late.
The CDC, in its draft of the guidelines, stated that patients will no longer have to sign a separate consent form for HIV testing but that screening will be voluntary and done with the patient's knowledge. The guidelines also call for providing verbal or written information about the meaning of a positive or negative test result. Right now, this information is relayed during pretest counseling, which would likely not be available at all places offering the test, such as emergency rooms.
But Will it Help or Harm Patients?
As some HIV/AIDS activists have noted, changing the new counseling guidelines could cause harm.
"HIV is not a routine diagnosis," said Ann Fisher, a lawyer and the executive director of AIDS Legal Council of Chicago. Because of that, pretest counseling and consent are integral aspects of HIV screening. Even today, AIDS patients face discrimination. They can lose their jobs and can still experience difficulties obtaining life or health insurance, she said.
All these things should be explained to patients before they are tested, said Fischer, who calls the new guidelines "stealth testing."
Other activists worry that the availability of care for those newly diagnosed is already insufficient, and that people who test positive under the new system may not have any way to get treatment.
"I would support expanded screening if there was greater access to care," said Jeff Sheehy, an HIV/AIDS activist and policy adviser to San Francisco's Mayor Gavin Newsom. "We are putting the cart before the horse." Before implementing new guidelines for wider testing, he said, "we need to make sure that all who are newly diagnosed have access to health care and treatment."
These are important things to consider, said Dr. Myron Cohen, chief of the division of infectious disease at the University of North Carolina, Chapel Hill, but not reason enough to stall the CDC guidelines.
Cohen favors widespread, routine testing and added that it has been successful at yielding early diagnosis in the case of pregnant women. All pregnant women are offered HIV testing as a part of routine prenatal care.
"Once we detect more cases, more medications and resources will surface," said Cohen. "Also it is a tremendous cost savings to find people before they are ill."
D.C. Docs Have Mixed Views
In Washington, doctors had a similar mixed reaction.
"It's a good idea, but its impractical [in the emergency department setting] without the addition of significant resources, said Dr. Robert Shesser, chairman of George Washington University emergency department. He also said a lack of counselors and follow-up could pose potential problems.
However, Dr. John Hogan described it as "refreshing and encouraging."
"I don't see why it's not a reachable goal," said Hogan, a primary care physician at Unity Health Care, a community health clinic in Washington.
Twenty minutes after getting tested, Miles is happy to know that she is negative and said she will get tested again next year.
If she is any indication, perhaps Washington will reach its goal.