Bay Area Reporter - September 28, 2006
Rob Akers

Mark Cloutier, executive director of the San Francisco AIDS Foundation, welcomed the new CDC guidelines as an important step toward "normalizing" HIV as an identifiable and treatable disease.

"It is the right strategy," he said.

He also lauded the recognition in the CDC policy that patients who test positive should be given access to care and treatment. But he remains concerned that Congress, in the reauthorization of the Ryan White CARE Act, may strip as much as $29.6 million from San Francisco's allotment during the next five years.

Much of the money lost to the large urban epicenters of the AIDS epidemic would be redirected to the South, where HIV infection rates are rising fastest. "It is robbing Peter to pay Paul," Cloutier said. "It harms one group to help another."

"Many of the 40,000 new cases of HIV infection that occur nationally each year could also be avoided if more HIV-positive people were encouraged to learn their HIV status," he said. "Removing barriers to HIV testing, while providing safeguards for informed consent and maintaining confidentiality will reduce new infections in the United States."

Federal health authorities formally called for a vast expansion of AIDS testing in the United States on September 21 in an effort to find the estimated 250,000 Americans who are infected with HIV but do not know it.

The new guidelines released by the CDC in Atlanta are three years in the making. The guidelines call for making HIV testing for patients ages 13 to 64 as routine as leaving a urine sample at the doctor's office. If the recommendations are carried out by doctors, all Americans from teens to aging Baby Boomers eventually would take at least one test to see if they carry antibodies to HIV, the virus that causes AIDS.

For the past 20 years, since the first HIV test became available, the policy emphasis has been on testing primarily those deemed to be at highest risk.

Under the new guidelines, doctors would tell patients they would be tested unless they say no. In that way, the HIV screening would still remain voluntary.

The new recommendations eliminate both pre-test counseling and separate written consent, which Cloutier believes have discouraged HIV testing for many at-risk individuals.

"Not only do these steps present a barrier to testing for people who may be at risk for HIV infection, but the time and paperwork they require discourages many physicians and medical providers from even discussing the importance of HIV testing with patients," he said.

Cloutier added that the revised recommendations must be accompanied by an increased commitment on the part of the federal government to assure the availability of primary medical care and treatment for those Americans who are diagnosed with HIV.

That sentiment was echoed by Project Inform's Ryan Clary, who said that agency's biggest concern "is that there is no concurrent plan to increase funding for HIV care and treatment programs."

"It is misguided public health to expand testing efforts without ensuring that there will be care and treatment available for those who test positive who are low-income and uninsured," Clary added.

Generally, Project Inform supports expanded offers of voluntary testing, although the agency disagrees with the CDC recommendations to eliminate pre-test counseling and informed, written consent, Clary stated.

The health department was cautious in its response, issuing a statement that was signed by HIV Prevention Section officials Tracey Packer, interim director; Teri Dowling, manager, HIV counseling, testing, and linkages; and Shelley Facente, quality assurance coordinator.

"The HIV Prevention Section firmly supports a person's right to choose whether or not to be tested for HIV. HIV testing must remain voluntary," their statement said.

The prevention section "supports access to HIV counseling and testing for everyone," including "routinely offered voluntarily HIV testing in medical settings."

But the officials also said that informed consent to test for HIV is critical and that "systems must be in place to ensure people are given enough information about the test and the implications of the results of the test to make an informed decision."

"Without this information testing cannot be considered voluntary," Packer, Dowling, and Facente stated.

Longtime AIDS activist Michael Petrelis said he welcomed the CDC recommendations.

"The CDC's long overdue recommendations to normalize HIV antibody testing is laudable and should do a lot to detect infections in individuals who otherwise wouldn't learn their status," he told the Bay Area Reporter in an e-mail. "I think routine HIV testing should have started back in the mid-1990s when protease drugs first became widely available, helping many people with HIV infection or full-blown AIDS to live longer, healthier lives."

Jennifer Hecht, education manager for the Stop AIDS Project, told the B.A.R. that one advantage to the new recommendations is the recognition that there are quite a number of people who are not aware they are infected with HIV.

But there are downsides, Hecht said, particularly with regard to removing the counseling component, which is a big part of HIV prevention work. During such sessions, counselors may discuss a variety of issues with clients, including behavioral risks that may have developed since a person was last tested, and other factors such as depression, mental health issues, substance use, and sexually transmitted diseases.

"HIV testing itself is not prevention," Hecht said.

With prevention agencies such as Stop AIDS already operating with limited funds, Hecht said it might be better to focus on programs that have a demonstrated impact, such as needle exchange and free condoms. The federal government, she noted, does not fund needle exchange programs.

On Tuesday, September 25, Stop AIDS and the AIDS Health Project unveiled a new mobile testing RV that will "bring testing to areas" where it's determined there is higher risk, such as parks, bars, and clubs where men congregate.

"We're bringing these services to very high-risk populations," she said. "The CDC is [calling for] testing nearly anyone and test a lot of negative people."

While Hecht said the CDC recommendations would likely remove some of the stigma attached to HIV, "the issue is the amount of prevention money remaining the same or decreasing over time."

Studies show that people who get tested and are diagnosed positive earlier live longer, healthier lives than people who learn their status later, according to information provided by SFAF. The foundation reported that nearly 40 percent of people diagnosed with HIV receive that diagnosis within one year of developing AIDS.

The CDC has indicated that it still must propose guidelines for implementing its revised recommendations. Cloutier said SFAF would review the proposed guidelines to make sure that they guarantee individuals' rights to be informed if an HIV test is to be performed, to have the meaning of the test and its results explained, and to opt-out of testing if they so choose.

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