Despite national guidelines issued by the US Centers for Disease Control and Prevention recommending that all Americans aged 13 to 64 be routinely tested in all healthcare settings, private, federal and state organizations have largely failed to do so.

This was the main theme of a national summit held this week in Arlington, Virginia, called the Forum for Collaborative HIV Research where 300 leading HIV researchers, policymakers and healthcare providers met to discuss new advances and barriers to routine HIV testing.

Many working in the field believe routine HIV testing is the key to slowing down the epidemic in the US where there are more than 1.1 million Americans living with HIV.

Last year nearly 60,000 people were infected with HIV in the US, where 50 to 70 per cent of new sexually transmitted infections are spread by Americans who don’t realize they are infected, said a statement issued by the Forum for Collaborative HIV Research.

Director of the Forum, Dr Veronica Miller said:

“Two years after the CDC recommended routine testing, initial successes show its potentially powerful impact, but major barriers keep it from being the national norm.”

“With HIV, ignorance is not bliss” said Miller, explaining that people who don’t realize they are infected are three times more likely to pass on HIV.

Conference co-chair and Director of the Brown University AIDS Program, Dr Ken Mayer said:

“The healthcare system is routinely missing critical opportunities to identify and treat HIV-infected individuals — in emergency rooms, doctors’ offices, veteran’s hospitals and prisons.”

The result is that many people aren’t tested until the later stages of the disease, even when the symptoms are quite evident, he said.

Dr Richard Rothman of the Johns Hopkins University Department of Emergency Medicine told the Forum that since the CDC issued its recommendations in 2006 routine testing for HIV in Emergency Rooms (ERs) has improved minimally with only 50 to 100 of the 5,000 ERs nationwide routinely testing for HIV.

This is a missed opportunity said Rothman because there is evidence that of the 2.8 million ER tests performed over the last 12 years, 6 per cent were HIV positive, much higher than the national prevalence of AIDS in the US population.

And according to a number of studies it is not just ER patients, who are largely uninsured, but also people with full private coverage who are going untested. One study that reviewed insurance claims from plans covering nearly 8 million members found that in 2006 under 5 per cent of insured people with illnesses potentially linked to AIDs were tested for HIV.

Another study found that only 36 per cent of insured people treated for sexually transmitted diseases were tested and yet they represent a high risk group for HIV. And despite the fact prison inmates are 2.5 times more likely to be infected than the average American, most correctional facilities at state and federal level don’t routinely test for HIV, they only test inmates thought to be at higher risk.

Another high risk group is veterans. In the year up to the end of September 2006, fewer than 10 per cent of inpatient and 5 per cent of outpatient veterans were tested. Here the situation appears to be held back by the fact that under VA regulations HIV testing can only be carried out with written informed consent and documented counselling before and and after testing.

However, the Department of Veteran Affairs hopes this barrier will be removed when new legislation that President Bush signed last month kicks in that waives the need for written consent.

Miller said the point of routine testing is to stop transmission and getting people treated earlier.

“But new data show that late entry to care is a more serious problem than previously known and is costing years of healthy life,” she said.

The healthcare system is stuck in the past about HIV testing, said Summit co-chair Dr John G Bartlett, of The Johns Hopkins University.

“HIV testing started in 1985 when there was no treatment, a morbid death, an unrealistic fear of contagion and terrible stigma,” said Bartlett.

“Now HIV is treatable, we have a test that takes minutes and costs ten dollars. Individuals benefit enormously from treatment, as does society,” he added.

Another barrier is the attitude of ER staff who appear to be unaware of the new guidelines and the evidence supporting them. Surveys of ER staff often show that most of them oppose testing. Other barriers that showed up in a survey include lack of funding and the increased burden on ER staff.

The Summit also heard about the many successes including:

  • A voluntary HIV testing scheme taken up by up to 25,000 New York City inmates between 2004 and 2006 showed that 30 per cent of the men and 23 per cent of the women who tested positive did not know they had HIV and of these 90 per cent were neither men who have sex with men nor intravenous drug users showing the shortcomings of testing only in high risk groups.

  • A Chicago ER employed two health educators offering rapid HIV testing and over 15 months nearly 2,000 patients took up the option. 15 of them (0.8 per cent) were found to be HIV positive and were linked to care, although one patient, who was tested in a late stage of the infection, died in hospital.

  • Some cities have brought in innovative and proactive schemes. In New Orleans, for example, mobile testing vans are reaching Latino immigrant groups, and men who have sex with men are taking up offers of HIV testing in bars and bath houses. Cities like Oakland, California, Washington, DC, and New York City, and states like Florida and North Carolina, have also brought in widespread schemes that reach out to high risk groups.

  • Chris Barnhill, a 21 year old man, found out he was HIV positive at 16 when Metro TeenAIDS came to his college in Washington DC. He had been infected at birth. He said if he hadn’t had the test he would just have got “sicker and sicker”. “I wouldn’t have known what was going on,” he said, “I would have found out on my deathbed that I had AIDS, when it would be too late”.

  • State by state, policies are slowly changing. Since 2006 at least 16 states have passed legislation that brings practices more in line with the CDC guidelines, although 10 states are still incompatible with them.

Mayer said that many “model” programs are showing what’s possible and now all that remains is for the country to move from “isolated successes to a national movement”.

“The barriers must be removed,” he added.

Sources: Forum for Collaborative HIV Research.

Written by: Catharine Paddock, PhD