Saturday, September 23, 2006

Gadfly takes requests, part I - HIV testing changes

One of my earliest and most loyal readers has requested comments on two recent pieces in the New York Times. As I try to be as customer-friendly as possible, I am only too happy to oblige.

The government has recommended HIV tests as part of routine medical care, a change from their historical position. Bravo. We're 25 years into this thing, AIDS is a disease with existing but imperfect treatment options, and it is time we regularly treated it as such.

Not everyone agrees, however:

"Rose A. Saxe, a staff lawyer with the AIDS Project of the American Civil Liberties Union, said her group opposed the recommendation because it would remove the requirement for signed consent forms and pretest counseling. In settings like emergency rooms where doctors are strapped for time, Ms. Saxe said, 'we’re concerned that what the C.D.C. calls routine testing will become mandatory testing.'

Patients, particularly teenagers, she said, 'will be tested without an opportunity for understanding the magnitude of having a positive result.'"
I think this type of testing should follow the model of blood work, which gets screened for lots of things (doctors in the audience, help me out with other examples of things blood is normally tested for). If I ran the world, someone who consents to blood work consents to the rest of the medical tests that would normally go with it (unless they specifically ask to opt out, I guess) What could a rational, intelligent, defensible position be for not knowing one's HIV status, especially in 2006? I don't sign a special consent to find out my cholesterol levels, and I see no need to do so for an AIDS test.

As for the idea of the need for deep, pretest counseling? Nonsense. What other diseases do we require this type of approach for? I go in for a check-up, and might wind up having a prostate exam. The doctor doesn't spend time with me beforehand to explain that - even if he feels something and even if it eventually turns out to be prostate cancer - in general prostate cancer grows very slowly, and if we catch it early there are a variety of courses of treatment available, etc. No, that is not done; instead we cross that bridge when we come to it. Of course it would be terrific if we all had lots of pretest counseling, became perfectly-informed patients, etc. But to stipulate it as a requirement, and by extension prevent testing when it does not occur, is in my mind wrong.

Once again, AIDS is a disease. We all benefit - those who are or will be sick most of all - from people knowing when they are infected/sick with a disease. Attempts to continue to treat AIDS as in a "special" category are wrong-headed, and a long time past their prime.


Katrina said...


One more scenario to put into the mix. During the course of taking care of a person found passed out on a street corner, a ER physician is stuck with a contaminated needle. The patient cannot be tested for HIV without the patient's written consent. If consent was not obtained, the ER doc would be treated with HIV prophylaxis and then have to wait the several months to determing whether or not they were infected with HIV from the needlestick.


Gadfly said...

Personally, I think anytime a person is potentially infected in cases like that through their official capacity (e.g. police officers, ER doctors, paramedics), testing the potential source should be mandatory. I know that this is a privacy intrusion, but in this case other interests should control. Even things like freedom of speech have limits, such as the classic example of shouting "fire" in a crowded theater. In this limited case the health interest of the public servant should outweigh the privacy concerns of the other person.

By the way, I'm putting aside how horrible a person one has to be to have potentially infected a doctor, etc. and then refuse to agree to be tested. Legalities aside, that is just something horrible and indefensible to do.

Jim Lippard said...

Are you proposing mandatory AIDS testing as part of ordinary bloodwork, suggesting that it's a good idea for doctors to do it by default without the knowledge or consent of patients, or something else? Please keep in mind that most people in the United States are at extremely low probability of having HIV infection--it is transmitted primarily through specific identifiable risky activities. It doesn't make sense to do blanket testing of populations outside of those that engage in those activities, because even a highly accurate test will have more false positives than true positives for a population with a low baseline rate of infection. And the costs (especially opportunity costs) will outweigh the benefits. This is why states that required mandatory HIV testing for a marriage license discontinued the practice--it wasn't remotely cost effective to spend $1 million in testing to find one person with HIV.

This is the same reason that it's a bad idea to do random drug testing of fifth graders--you'll end up making false accusations more frequently than you find drug users.