TARGETED OR UNIVERSAL SCREENING?
Under the direction of President Obama, who has said the US “is at a crossroads” in terms of HIV/AIDS, facing “a domestic epidemic that demands a renewed commitment, increased public attention, and leadership,” the White House Office of National AIDS Policy (ONAP) has set ambitious goals for HIV prevention. Outlined in the National HIV/AIDS Strategy for the United States, those goals—with a deadline of 2015—include:
• Decrease the annual new HIV infection rate by 25%.
• Decrease the HIV transmission rate (currently 5 persons infected per year per 100 people living with HIV) by 30%.
• Increase the number of people living with HIV who know of their infection from 79% to 90%.
• Increase the number of people with newly diagnosed HIV who have regular health care within three months from 65% to 85%.
The strategy (available at www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf) was commissioned and developed in response to concern that without bold action, “we face a new era of rising infections, greater challenges in serving people living with HIV, and higher health care costs,” as stated in the executive summary of the report.
It may not help the cause that health care providers receive seemingly mixed messages about how to approach HIV screening. Since 2006, the CDC has recommended routine screening for HIV, stating that “HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening).” The CDC expressly recommended that separate written consent and prevention counseling should not be required, in part as an acknowledgement that busy practicing clinicians who have to screen for a multitude of conditions and often provide acute care during an office visit are under time constraints.
“That doesn’t mean you don’t do any counseling at all,” says Julie G. Stewart, DNP, MPH, MSN, FNP, Assistant Professor and Coordinator of the FNP Program at Sacred Heart University and an HIV NP at Southwest Community Health Center in Bridgeport, Connecticut, “but having discussions with your patients about their life and their health and their risk factors in every facet should include HIV testing.”
At the same time, both the CDC and ONAP emphasize that certain populations are at higher risk for HIV infection and therefore need to be targeted. These include:
• Gay, bisexual, and other men who have sex with men: 2% of the US population but 61% of new infections (2009 data)
• Black men and women: 14% of the population but 44% of new HIV infections
• Hispanic and Latino persons: 16% of the population but 20% of new HIV infections
• Injection-drug users: 9% of new HIV infections
The CDC also reports that heterosexual persons account for 27% of new HIV infections.
In a tough economic climate, when the US investment in response to the domestic HIV epidemic has risen to more than $19 billion per year, it makes sense to strategize how to most effectively utilize available resources to reduce disease burden. But do we run the risk of missing cases because we make too many assumptions about who is or is not likely to have this infection?
“The information that has been pushed out there has really tried to focus on these high-risk groups—and yes, we understand that those groups need to be identified,” says Ogunfiditimi. “But when you’re trying to increase the amount of testing, then the message needs to be more general so that practitioners who have natural biases won’t implement those biases into their decision as to whether to test someone.”
“What worries me is that the recommendation has been to test everyone at least once, and then again as indicated,” says LeLacheur. “‘As indicated’ means you have to ask. In parts of the country where HIV is not as prevalent as it is in DC, I can understand how it falls off the radar. But there are still a few [cases]—maybe not one in 20, maybe more like one or two in a clinician’s lifetime—and there is just no telling from the outside.”
“Perception of risk is huge,” adds Stewart. Her state was one of the first to mandate prenatal HIV testing, and she recalls instances in which a woman tested positive and the clinician was shocked because, Stewart says, “the perception was that ‘She is not at any risk at all,’ based on where she lives and her background. But the clinician didn’t really know.”
LeLacheur also points out that assumptions work both ways: “Oh, he’s a nice boy” and “Oh, he’s not a nice boy.” In one of her classes, a gay male student shared his experience seeking a diagnosis for what turned out to be Crohn’s disease. “The minute he told his clinician he was gay, all of a sudden he had AIDS and the clinician wouldn’t look anywhere else,” LeLacheur reports. “And that just wasn’t an issue; this was a kid who had been raised in an era of safer sex and had been very careful.”
Advocates say that implementing universal screening, per the CDC’s recommendation, would not only capture more cases but would also reduce the stigma associated with targeted screening.
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