More on HIV testing (Health Management, Feb. 2007)

CDC's revised HIV recommendations that all people aged 13 to 64 should have routine HIV testing may be effective in the public health setting, but might not be as effective in the private setting, according to one expert.

"Some of the evidence used by CDC to promote these guidelines is from public health sites, where the demographics and dynamics of providing care are very different. The emergency room often serves as the primary site of care in the public health setting and the only place where individuals come in contact with a medical professional," Michael Allerton, HIV operations and policy leader for The Permanente Medical Group in Oakland, Calif., explains. "In addition, often in the private setting, only a licensed physician can order an HIV test and conduct informed consent, while a medical assistant or trained counselor can give the test in a public health clinic, making the process more efficient."

Kaiser Permanente's Northern California region conducted more than 81,000 HIV tests in 2006 and identified 451 new cases. About 5,500 of Kaiser Permanente's 3.2 million members in Northern California have been diagnosed with HIV.

"Routine testing is best for a set [or static population], such as those who have a genetic predisposition or a condition that doesn't change," Allerton says. "HIV infection is dynamic; new infections are constantly occurring, so a screening today will not find those infected tomorrow." He emphasizes that constantly testing everyone 13 to 64 years old is not the most efficient or effective strategy. Allerton also stresses the relevance of yield: "If you are doing thousands of tests and not finding many positives, it isn't a question of cost but one of efficiency and priorities," Allerton says.

California is one of at least eight states with laws that require pre-test counseling and separate informed consent from patients, which may make the new CDC recommendations difficult to follow. Allerton says it is important to find a way to make the law work within the revised recommendations. He doesn't believe it is necessary to eliminate the state requirements, but perhaps make changes, such as allowing professionals other than physicians to conduct the testing.

"Legislation could provide good leverage to conduct more testing," he says. "We need to find more people with HIV sooner. For certain populations: pregnant women; those who already have an STD or are suspected of having one; and those for whom an HIV test is recommended but not accessible during the patient visit. The payoff would be monumental."

The revised recommendations arrived on the heels of April 2006 California state legislation that changed reporting of HIV infections to public health officials by code to confidential, name-based HIV reporting. Allerton says there is concern that members will not come in for healthcare for fear of loss of confidentiality.

The San Francisco AIDS Foundation sanctioned the change based on data that showed that name reporting did not deter individuals from being tested for HIV. If California had not passed the legislation, it would have risked losing substantial federal AIDS funding. The California Medical Assn. also endorses the CDC recommendations.

Allerton says that Kaiser Permanente has not yet made a decision on whether to adopt routine HIV testing among its members, but is committed to doing more testing and to develop strategies to accomplish the same goal. "One size doesn't fit all; it is a complicated guideline," he says.

Jeremy Brown, MD, research director for the Department of Emergency Medicine at George Washington University in Washington, D.C., is not convinced that the revised CDC recommendations will work in the emergency room with limited resources to conduct the test and report the results.

On the other hand, he agrees with the CDC that various healthcare settings such as the ER present an opportunity to test patients, especially those who are young, healthy and uninsured.

"That's a group that is at high risk for carrying the infection and not knowing about it," he says.