The New York Times - September 22, 2007
Jeremy Brown, Op-Ed Contributor

TWENTY-FIVE years after the outbreak of H.I.V. in the United States, there are about 40,000 new cases of infection a year, and an estimated quarter-million people who have H.I.V. but do not know they are infected.

That's why the Centers for Disease Control and Prevention has recommended that every emergency room patient ages 13 to 64 should be offered an H.I.V. test. It doesn't matter if the person is there for a sprained ankle, a cut finger or appendicitis: the C.D.C. wants him to be offered a test for H.I.V. New tests requiring only a painless swab of the gums can reveal in 20 minutes if a person is infected.

If the problem is so serious and the solution so simple, then why, one year after these recommendations were made, are there are still almost no emergency rooms that offer routine H.I.V. testing?

It all comes down to money. Although the C.D.C. recommendations were based on impeccable science and more than two decades of experience in dealing with the disease, they did not address the question of how this universal testing campaign would be paid for.

Health insurers generally pay for an emergency room visit based on the final diagnosis. An H.M.O. will pay a fixed amount for a sprained ankle, for example, whether the patient had an X-ray, an M.R.I. or no costly imaging test at all. So if the patient with a sprained ankle receives an easy-to-perform but unrelated H.I.V. screening, the hospital is unable to recover the additional fee. And in those states where H.I.V. tests are not distributed free of charge - and this includes virtually all of them - or where no extra staff members are available, it is simply not possible to offer an H.I.V. test as the C.D.C. recommends.

At my own hospital, just a few blocks from the White House, in the first year of a program offering H.I.V. screening to emergency room patients, we tested more than 4,000 people. But we were able to do this only because we received a generous grant from a major pharmaceutical company and free test kits from the District of Columbia Department of Health, and because we could divert some of our staff from their usual activities.

During the past year, more than 60 percent of emergency room patients have accepted the H.I.V. test when it is offered. Seventy-five percent of those patients told us they thought the emergency room was a good place to get tested for H.I.V., and more than 80 percent would recommend it to a friend.

Our screeners have been approached countless times by family and friends accompanying patients who, when hearing of our H.I.V. screening program, ask to be tested. We've identified many new cases of H.I.V. in patients who had no idea they were infected, and then started them on long-term care. Yet if our grants were to run out tomorrow, this program would stop.

If health insurers reimbursed emergency rooms a mere $40 in addition to the usual medical charges for every patient tested, H.I.V. screening programs like ours would be self-sufficient. We could purchase all the tests we need without grant money, pay for the extra staff to perform screenings and even test patients who lack insurance. H.M.O.'s already pay for all kinds of health care screening, from cholesterol tests and Pap smears to mammograms and colonoscopies. Emergency-room H.I.V. tests should be no exception.

Each year in the United States, there are about 115 million visits to emergency rooms, which often serve as the only medical point of contact for those most at risk from the H.I.V. epidemic. The C.D.C. recommendations can help us identify those who need to be on life-saving therapies but are simply not aware they are infected. Unless we compel insurance companies to pay for these simple, proven, relatively inexpensive tests, however, this major public health initiative will amount to nothing.

Jeremy Brown is the research director at George Washington University Medical Center's department of emergency medicine.

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