Comments On CDC's Revised Recommendations For HIV In Health Care Settings

Date: March 29, 2006
Organization Name: San Francisco AIDS Foundation
Contact: Dana Van Gorder, Director of State & Local Policy
415.487.3099 dvangord@sfaf.org

The San Francisco AIDS Foundation appreciates the opportunity to provide comments on the "Revised Recommendations for HIV testing of Adults, Adolescents, and Pregnant Women in Health care Settings" proposed by the federal Centers for Disease Control and Prevention (CDC) on March 8, 2006.

Our comments apply equally to multiple categories listed on the cover sheet provided for formatting purposes, and so, we include the entirety of our text here rather than breaking it apart. We apologize for any inconvenience as a result of this.

Established in 1982, the San Francisco AIDS Foundation (SFAF) is one of the oldest and largest community-based AIDS service organizations in the United States. The mission of the agency is to end the pandemic and the human suffering caused by HIV. To that end, we provide a comprehensive array of services -- including financial benefits counseling, client advocacy, housing assistance, HIV prevention efforts, syringe exchange, and the California AIDS Hotline -- that directly serve over 100,000 individuals affected by HIV/AIDS. We reach over 1.5 million others through community outreach, prevention campaigns, and the Worldwide Web. Additionally, the Foundation operates a Public Policy Department that is recognized as a leading voice in efforts to assure a sound governmental response to the HIV/AIDS epidemic.

The San Francisco AIDS Foundation is troubled by the fact that a significant number of Americans who are infected with HIV remain unaware of their HIV status. Current approaches to HIV screening have thus far been unable to fully assure the public health by encouraging the acceptance of HIV testing as a routine part of medical care. SFAF therefore supports the important goal set by the CDC in its revised recommendations regarding HIV testing in health care settings - to significantly increase the number of Americans who are tested for HIV tests, regardless of their known or perceived risk for HIV infection. There can be little doubt that the health of thousands of people at-risk for HIV infection would be improved and that the health of their sexual partners and children would be better protected if new strategies are implemented to assure that more adolescent and adult Americans are tested for HIV infection on a regular basis.

At the same time, SFAF believes that all individuals have a fundamental right to be fully informed about any and all medical procedures that are to be performed on them and to choose whether or not to undergo those procedures. In order to be effective over time, a patient-provider relationship is most likely to be effective if is marked by transparency, cooperation and trust. Sound medical ethics dictate that patients be informed if they are to be tested for HIV and that they have the right to decline such testing without any negative repercussions if they make that choice.

The prospect that an individual has or might have HIV disease continues to be burdened with significant emotional and psychological weight, not unlike that experienced in connection with other life-threatening illnesses, such as cancer. Because of its emotional and social consequences, reasonable people would agree that being tested for HIV infection is not a simple or routine matter and it would be a mistake to suggest that most Americans view HIV so neutrally that they would not insist on being informed by a medical provider that they will be tested for HIV. Greater sensitivity and communication must therefore mark physician efforts to discuss and diagnose HIV than what is required for many other medical conditions.

Additionally, in many communities across the nation, ongoing experiences of stigma and discrimination related to HIV/AIDS continue to be a very real barrier to the willingness of many people at risk for HIV infection to seek testing. This fact provides further evidence of the need for physicians to involve patients fully in decision-making regarding HIV testing, care and treatment, as well as to provide complete confidentiality of patient information regarding HIV infection, consistent with applicable laws.

Finally, SFAF believes that while increasing HIV testing rates is a key goal, it is equally important to ensure that those who test positive have access to comprehensive medical care and treatment for their HIV disease. As the CDC notes in its rationale for the new recommendations, "Effective linkage of newly diagnosed patients to care is essential: screening without such linkage confers little or no benefit." It is therefore incumbent upon the CDC to work closely with the Department of Health and Human Services and other federal agencies to prepare for a significant increase in need for both public and private health care services that will result from this laudable effort to identify previously undiagnosed cases of HIV infection. It is also incumbent upon the federal government to address the current under-funding of programs that will be needed to assure adequate prevention counseling, partner counseling and referral services, substance abuse and mental health services and other social services for those individuals who test HIV-positive as a result of these new testing guidelines.

With these as guiding principles of our approach to HIV testing and counseling, SFAF supports many of the recommendations included in the Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings. We would, however, make the following specific comments regarding the proposed recommendations:

1. General consent for medical care is not adequate to grant physicians and other medical providers permission to test individuals for HIV infection without their specific knowledge and agreement. We believe that each and every time an individual is tested for HIV, the provider should explain that he or she recommends the test as a routine part of thorough and responsible medical care, even if the patient believes they are at no or low risk for HIV infection. This recommendation should always be expressed in non-judgmental ways in order to reduce the likelihood that a patient refuses to be tested.
2. When offering an HIV test, a provider must always explain the purposes of the test and the meanings of both a positive or negative test result. The provider must also permit the patient to ask questions about the reasons for and implications of the test.
3. Patients have many reasons for avoiding HIV testing. Some of those reasons may prove legitimate and should be respected. Others are clearly unfounded or irrational. The CDC's goals for HIV testing would be well served by an effort to better train providers how to sensitively elicit from patients any potential reasons why they may not want to be tested for HIV infection in order to address those concerns and increase the likelihood that a patient will agree to be tested.
4. While we believe that a patient's consent to HIV testing does not need to be documented in writing, we also believe that each time a provider recommends a routine HIV test, a patient must be given an opportunity to indicate that he or she does not consent to be tested for HIV infection. That desire must be honored without any repercussions for the individual who has opted not to be tested
5. While it would be optimal for physicians and medical providers to counsel all sexually active patients regarding HIV risk reduction techniques and/or provide counseling at the time of an HIV test, neither should be required. Again, the CDC's goals would be well served by a program to better train physicians and other medical providers regarding effective HIV risk reduction and HIV test counseling. All providers who cannot or will not provide this counseling should offer referrals to HIV risk reduction or HIV test counseling programs as requested by the patient at the time of a test.
6. We have concerns about the CDC's recommendation that "HIV test results should be provided in the same manner as results of other diagnostic or screening tests." HIV test results are sensitive and confidential information that is burdened with significant emotional and psychological weight and should be handled as such. Under no circumstances should the results of an HIV test, whether positive or negative, be provided to a patient in a manner that would undermine the patient's confidentiality. And, as suggested later in the recommendations, HIV-positive test results should be communicated through direct personal contact.
7. The CDC should assure the training of physicians and other providers to counsel newly diagnosed HIV-positive patients about the meaning and implications of their test result and ensure true informed consent when offering an HIV test to a patient. This counseling should include recommendations about follow-up medical care and possible treatment, HIV risk reduction techniques to avoid infecting others, and voluntary partner notification. If the provider is not able or willing to provide this post-test counseling, they must be able to provide referrals to programs that can do so.
8. It is critical that, consistent with state laws governing the lawful reporting or disclosure of HIV infection, patients be assured by their medical providers of complete confidentiality regarding their HIV status or HIV risk behaviors. Nothing will serve as a greater deterrent to the success of the CDC's efforts to increase patient acceptance of and compliance with testing than any real or perceived beliefs by patients that they may suffer harm from extra-legal breaches of the confidentiality of their HIV status. We therefore recommend that the CDC accompany this testing effort with guidance to physicians and providers describing the confidential nature of HIV-related information pertaining to their patients.

Once again, the San Francisco AIDS Foundation appreciates the opportunity to offer comments on the CDC's important efforts to increase HIV testing in clinical settings in order to identify previously undiagnosed cases of HIV infection. We are eager to continue working with the CDC in the development of these and other guidelines around HIV prevention, counseling and testing. If we can offer any immediate assistance or answer any questions or concerns you may have regarding our comments, please contact Dana Van Gorder, Director of State & Local Policy, at 415-487-3081 or at dvangord@sfaf.org.