The Case for More Aggressive HIV Testing

Why can’t testing for HIV become more routine and consistent?  

I also believe that current CDC guidelines are too conservative and leave too many cracks for someone to fall through in seeking/remaining in care.    

Establishing a new norm is difficult but not impossible. Research has shown that providing incentives and massive outreach are two tools necessary for establishing the norm for testing in Africa. We have already gotten our foot in the door as far as HIV testing goes, but I believe it is time to throw that door wide open and really create the political will to curb the rise in new HIV infections.

I believe creating a new, more aggressive testing norm is possible here in the US as well.

We already have a medical framework to support testing and follow up...primary care physicians, ER rooms, health departments, HIV organizations. It would not take much more time, money, or infrastructure to ramp up HIV testing in the medical frameworks that are already in existence. It seems to me it is easier to add on to something than to start from scratch.

According to AIDS, the official journal of the International AIDS Society, a recently published study by Northwestern University researchers confirmed that current guidelines are not aggressive enough.  The study found that optimal testing frequencies should be much closer together for each risk category.  For patients in the highest risk category it was found that a person at high risk should get tested every 3 months. Current CDC guidelines, last updated in 2006, recommend annual testing for those at high-risk. Current CDC guidelines, last updated in 2006, recommend annual testing for those at high-risk.

A patient is considered at high-risk for HIV if they are male and have had unprotected sex with a male, had unprotected sex with someone known to be HIV+, shared needles or syringes to inject drugs/steriods, or if you received a blood transfusion between 1978-1985

The AIDS study also recommended more frequent HIV testing for those in low or moderate risk for HIV, yearly for those at low to moderate risk of HIV.  Similar studies in Africa also replicate these findings, showing more frequent counseling, testing, and treatment can reduce new HIV transmissions.  A person must first test positive for HIV before treatment can begin.  

There is also a financial cost savings that results from more frequent HIV testing. Given current idea of treatment as prevention, it would be more cost effective for someone at high-risk be tested once a quarter and this could allow treatment to begin sooner and allow time for an HIV+ person to achieve an undetectable viral load, thus reducing the risk of transmission.  A person on successful ARV treatment (those who have an undetectable viral load) are 96% less likely to infect their sex partners. And that 96% reduction on risk results are from only implementing TrasP (treatment as prevention); if you add in condom usage and PreP (pre-exposure Truvada) then the risk reductions are even greater. 

Very recent clinical findings from France indicate very early HIV treatment can possibly provide a functional cure in 10% of patients.  In the French study, it is indicated that beginning ARV treatment within 10 weeks of infection and sustaining ARV therapy for an average of 3 years can create a functional cure/remission in 10-15% of the participants.  This study would seem to provide hope that these findings could be translated into clinical practice, but to duplicate these results would require a much more aggressive testing campaign than what the CDC recommends, testing guidelines that replicate the Northwestern University study.

Though the United States currently conduct about 2.1 million HIV tests a year, almost a third of those who test positive do not come back for their HIV test results [6, 9].  If the testing was conducted anonymously, then those patients never can be offered care because they could not be tracked down.  The CDC recommends prevention counseling is not needed if the test if given in a medical setting such as a hospital or doctor’s office [6].  This is meant to reduce a barrier in HIV testing because the CDC believes health care settings are too busy to provide prevention counseling [ 6].  

As I read the CDC guidelines for testing in a medical setting, it sounds to me as if the CDC is saying that hospitals and doctor’s offices are too busy to provide HIV prevention counseling to patients.  My fear is that an HIV test will be given, a person will test negative, and that person will go out and engage in high-risk activities (unsafe sex, IV drug use), comforted by their negative test result.  Without prevention counseling, it is conceivable that those who receive a negative HIV test result may revert back to unsafe behavior.  After all, a negative HIV test result only relates to past exposure.  

I believe the CDC should recommend prevention counseling in all testing settings, not just for the non-medical testing settings.   

There are also personal benefits to expanded HIV testing.  Knowing one’s HIV test results allow one to be proactive in making safer, healthier sexual choices. Two-thirds of those who test positive for HIV immediately eliminate or reduce risk behaviors so as not to pass on their HIV to others. Just knowing one's HIV status in itself provides a reduction in further infections.

If one tests positive, it allows a patient to begin ARV therapy sooner, thus having a higher chance at salvaging immune health.  Knowing your HIV status also allows a mother to be able to determine the safety of becoming pregnant, and allow the mother-to-be to receive prenatal HIV ARV therapy should she test HIV+, thus greatly reducing the chances of transmission to her child.  

Even a fear of needles should not be a deterrent to HIV testing as there are testing methods available now that test saliva.  Rapid testing can be performed in one medical visit, so that a patient may test and learn the status on the same visit.  Rapid testing would allow valuable counseling and linkage/coordination of care to begin should a patient test HIV+.  Expanded testing would also begin to establish a societal norm in that an HIV test would become a routine part of medical care, as is taking one’s temperature and blood pressure readings.