Just do it. HIV has been around for more than 30 years. We know it is a time bomb—about 10 years before symptoms show. We know it can be diagnosed and treated long before symptoms show. We also know it can be dealt with—medically and socially. But we have to be tested before any of those results can occur. Just do it might be better phrased as, “Do it, without thinking.” We got the “without thinking” part down,” but after 30 years we’re still not “doing it”—testing, that is.
Testing for HIV must become routine. The Centers for Disease Control (CDC) says it, the World Health Organization says it and President Barack Obama says it. Becoming routine leads to preventing the spread to others; eliminating the greatest obstacle, which is the stigma; and getting early treatment, which results in a long life.
The routinization of HIV testing has had a difficult path. That is somewhat strange given that its only objectives have included the following:
Prevention of the unknowing infection of others. Often the very people we love the most are the ones infected by the unknowing
carrier.
Example: One hospital reports that when married couples were tested routinely, 100% of the HIV negative persons were previously unaware of the positive status of their partner.
Example: The Veterans Administration (VA) announced that more than 10,000 patients were accidently exposed to HIV and other conditions resulting from failure to maintain operational standards. News reports say that inadequate sanitary practices at a Missouri VA hospital are to blame for exposing about 1,800 patients to HIV, as well as 3,400 patients at a VA facility in San Diego. The number of secondarily infected persons is unknown.
Example: In a three-year, 20-hospital study published in the New England Journal of Medicine, it was concluded that without routine testing more than 100,000 infected persons would have walked out of hospitals not knowing they were HIV positive.
Stigmatization evaporates when moral judgment takes a back seat. When the stigma is gone, the major obstacle to diagnosis and treatment is gone.
Erectile dysfunction is a great example. It used to be called “impotence,” which means weak and powerless. For centuries, men could not bring themselves to discuss it, even with other men. Scientists were subject to criticism if they wrote or studied the subject. Along comes Viagra, and within a few years the condition and the treatment has become so destigmatized that it is joked about in a Jack in the Box commercial. Like erectile dysfunction and even heart disease, HIV is a medical condition, not a moral judgment.
Early diagnosis and treatment for HIV, like most health issues, is usually the difference between preserving a quality life and living a deteriorating one.
HIV is very patient. Why? Because it knows the results in the absence of treatment. The CDC also knows the results of the absence of treatment. In 2006, it initiated an effort to incorporate HIV testing into routine medical care to the effect that “all patients aged 13 to 64 years be routinely tested for HIV at least once, regardless of perceived risk, and that those at high risk because of multiple or HIV-infected partners or other risk factors be tested at least annually.”
The CDC made the recommendation for routinizing testing as early as 1986 with subsequent updates. According to the CDC, best medical practice requires diagnostic HIV testing and opt-out HIV screening as a part of routine clinical care in all healthcare settings while also preserving the patient’s option to decline HIV testing and ensuring a provider-patient relationship conducive to optimal clinical and preventive care.
In a dusty village in Kenya, surrounded by ecstatic villagers, the grandson of a Kenyan sheepherder, then Sen. Obama and his wife Michelle stepped into a makeshift tent and were tested for HIV. Since he became President, Obama has continued to advocate for the importance of routinizing HIV testing. His message: Just do it.
The United States and every European country now routinely test pregnant women, and routinization has become commonplace in a number of settings. But can we accomplish the goal of the President and the CDC that a patient’s HIV status be part of routine medical care?
There are an estimated quarter of a million persons in the United States with undiagnosed HIV. They are not only unaware but also innocent. They could be the college student sitting two rows down that you have your eye on, the best singer in the church choir, your lawyer, your dentist, your spouse or your partner. According to Alison Yager of the HIV Law Project, the reason is, in part, that “current HIV screening practices reflect outdated assumptions about risk and the demographics of HIV. Risk assessments typically focus on known risky behavior of the individual or their sexual partner(s). Yet a partner’s infidelity or history of injection drug use, for instance, are often unknown.”
Besides of the failure of risk assessments to identify true risks, those groups once considered low risk are no longer necessarily so. Women, young people, African Americans, Latinos and individuals living outside of metropolitan areas all represent an increasing proportion of infected individuals. The result is that those in the new demographics may already have HIV. They are not being tested and remain unaware of their status. In addition to the large window to unknowingly infect others, the illness has a significant head start on treatment by the time symptoms appear. Tragically, one-third of new HIV diagnoses are made late in the illness. Women with no risk factors constitute a group increasingly vulnerable to infection from undiagnosed HIV.
Except for major hospitals in major cities, few hospitals follow the CDC’s recommendations. Those that do test could be considered as simply applying modified “old demographics,” that is, much of their population belongs to high risk groups. An informal estimate is that out of 5,000 emergency departments in the United States, about 50 to 100—mostly concentrated in a few areas—are routinely testing all patients for HIV.
It is evident that the CDC’s 2006 recommendation that HIV testing should be essentially universal in healthcare, even for low-risk patients, has been largely unheeded. Many clinicians have not gone along for reasons that center on money and time. Payment and reimbursements issues, staff time constraints, and concerns about informed consent and the availability of counseling all contribute to low compliance with the recommendations.
For now, it looks as if no one is going to do it until the money and resources are there. But the tests are available for anyone with enough initiative. In addition, they are free. So just do it. Get tested.
Note: Sources, reference Web sites and complete quotes available on request.
