Editor’s note: This is a response to “Routine HIV testing is a flawed strategy” by Isaiah Webster published in the July 29 Blade and available here.
Isaiah Webster questions whether the routine integration of HIV testing as a medical standard of care is a sound strategy and suggests that doing so is “misguided and lazy.” His views on HIV screening are surprisingly myopic and illustrate how little success we have had in framing HIV as a chronic, treatable disease that warrants integration as a routine health service.
I am an infectious diseases physician and see the impact of our failure to implement routine HIV testing into primary care. In the short time I have been practicing in the District, I have encountered many patients, already in primary care, whose stories illustrate why opposing routine HIV screening is errant and harmful for public health. I offer a few of these examples as a rebuttal to several points in Webster’s editorial because they represent missed opportunities for HIV screening in medical settings.
A 42-year-old heterosexual male was diagnosed with HIV in 2009. He reported no sexual activity or drug use in the previous two years. Soon after his diagnosis, he was admitted to the intensive care unit with his longtime girlfriend at his bedside. She confirmed a 12-year sexual relationship.
A 39-year-old gay man with hypertension and hypercholesterolemia who was never tested for HIV until he developed intractable diarrhea.
A 59-year-old woman hospitalized with pneumonia was not tested because she was married.
These cases are neither isolated nor unique. There are many more. The risk-based screening strategy Webster is supporting would have missed each of these cases. The point of the CDC testing recommendations, in part, is to eliminate the provider “guesswork” in deciding who is at risk for HIV infection. As illustrated by these cases, providers repeatedly demonstrate that we are unable to accurately assess or predict who has HIV infection. These cases also highlight that reliance on provider selection is an inappropriate approach because: 1. Patients are often untruthful and 2. Provider biases and perceptions interfere with the objectivity needed to discern risk.
Second, the CDC guidelines for routine HIV screening in medical settings are also meant to address the stigma attached to HIV testing. Perception is everything. If I am only asking some of my patients to be tested for HIV, this may trigger a cascade of emotions and perceptions that may present barriers to truthfulness and disclosure in our relationship. Whereas, if I routinely screen everyone in my practice just as I obtain a cholesterol level or a blood pressure, my patients begin to see this as part of the normal standard of care rather than a procedure only followed for “certain” patients. Furthermore, providers begin to frame HIV as a chronic, treatable disease such as cancer or heart disease. Whether advocates like, accept it or not, HIV is now a chronic, treatable disease.
Third, contrary to Webster’s opinion that routine screening is too costly, failure to integrate HIV screening into the medical setting is far more costly and severely exceeds costs associated with routine screening.
Webster is also concerned that routine HIV testing will deter doctors from spending time discussing sexual health and delivering HIV prevention messages. Actually, this is slightly amusing because I can assure Webster that doctors are already often inept at and infrequently hold these sexual health-related discussions with patients. I doubt the routine integration of HIV screening as standard of care would negatively impact our willingness or ability to hold these sensitive discussions. Ironically, because as a profession our performance in this area is just above abysmal, the integration is likely to have the opposite effect.
Webster’s posture suggests that proponents of routine screening integration believe that HIV screening in the medical setting is the “end all, be all” to identification of HIV infection. Few things could be further from the truth. In my opinion, HIV screening in the medical setting is the LEAST practical strategy for identifying HIV-positive persons. This is simply because screening in the medical setting as described, is costly since we tend to find people late in disease and when they are symptomatic and because we miss a huge segment of the population that never interacts with healthcare providers.
I emphatically and unequivocally support targeted and community-based HIV testing as a complement to HIV screening in the medical setting. It is our best means of both early diagnosis and achieving increases in community education and awareness. Shifting our approach a bit toward more targeted, community-based testing would then make HIV screening in the medical setting a “no-brainer”— simply because it would serve as a safety net for those we missed during community-based testing. Furthermore, a visit to a provider may be a person’s only opportunity for testing.
Let’s treat HIV like the preventable and treatable public health and medical challenge that it is and whether via community-based testing or in the medical setting, let’s get committed to the business of identifying and linking to care every HIV-infected person, not just in D.C. but in America.