US calls for making HIV testing routine

Most adults and all adolescents should be tested at least once for the AIDS virus, federal health authorities said yesterday as they unveiled a major shift in medical policy designed to make HIV testing as common as screening for diabetes and colon cancer.

The guidelines represent one of the most sweeping attempts ever to slow the epidemic in the United States. Disease trackers estimate that 250,000 Americans are infected with HIV but do not know it, and over the past decade, there has been little success in reducing the yearly number of new infections. It is not uncommon, specialists said, for people to carry the virus for 10 years or longer and not be aware they are infected.

Dr. Julie L. Gerberding , director of the US Centers for Disease Control and Prevention , said the guidelines are intended to identify infections sooner, get patients into treatment faster, and prevent further transmission of the virus, which is believed to infect 1 million Americans.

``When people know they're positive, the research has shown they take steps to protect others from infection," Gerberding said. ``People who don't know it continue to transmit the virus."

AIDS specialists said they could not predict how many people will be tested, but said the guidelines could alter the course of the epidemic in the United States.

Healthcare economists said universal screening for HIV is at least as cost-effective as tests that detect diabetes, breast cancer, and other chronic conditions -- because if an HIV infection is caught early, medicines can give patients a long, productive life.

``HIV testing is an excellent use of our healthcare dollar," said A. David Paltiel , a health policy analyst at Yale University School of Medicine .

AIDS testing has been largely confined to members of groups known to be at high risk for carrying HIV, such as gay men and injecting drug users. People getting the test give specific written permission and usually receive counseling beforehand aimed at preparing them for a diagnosis.

The CDC recommendations would change that. Now, all adolescents and adults 64 and younger would be told during a medical visit that they should be screened for HIV. Patients would still have the option to decline. Testing is not suggested for patients 65 and older because the incidence of HIV is relatively rare in that population.

Those patients believed to be at low risk of contracting HIV would typically undergo a single screening and would not have another test unless they acknowledge to their doctor that their behaviors have changed. Conversely, drug users and patients with multiple sexual partners would be encouraged to undergo annual testing.

Dr. Daniel R. Kuritzkes , a leading AIDS specialist at Brigham and Women's Hospital , said that unlike the early days of the epidemic, when patients were more stigmatized, there is no longer any reason to treat HIV testing differently from screening for other chronic diseases.

``There's no doubt this is the right thing to bring the epidemic under better control in the United States," he said.

Medical associations and AIDS advocacy groups yesterday were generally supportive of the new guidelines, but some argued that patients should still be required to give specific, written consent for the test. Under the new recommendations, permission to perform an HIV test would be covered by the consent form used to address cholesterol and liver tests, among other exams.

But a separate written consent for an HIV test would clearly give patients greater protection and guarantee they understand what they are being tested for, said Bebe J. Anderson , HIV project director for Lambda Legal , a national organization that advocates for the rights of the gay community.

``That has been the standard, and we think that should continue to be the standard," she said.

The new, more routine testing would avoid the problem of patients not acknowledging their risky behaviors, because ``patients don't have to admit they use intravenous drugs in order to get a blood test for HIV ordered," said Dr. Richard Marshall , chief medical officer of Harvard Vanguard Medical Associates in Boston.

Instead, for example, doctors, while noting that a patient is in need of a blood count and a urine analysis, would also mention that the patient hasn't undergone an HIV test. Marshall said he envisions that a doctor would then say: Do you have questions about that? Would you like a test?

Earlier studies in Massachusetts and an ongoing one in Washington, D.C., show that patients respond well to such an invitation. In 2002, every patient who visited the urgent care center at Boston Medical Center and three other Massachusetts hospitals was offered an HIV test. At first, only about 30 percent of patients agreed. Nine months later, twice as many patients consented to have the test.

``Early on they would say: `I'm here for a swollen ankle. I don't want an HIV test,' " said Dr. Rochelle Walensky , an AIDS specialist involved with the study. ``But when they realized you were not asking them if they wanted an HIV test because of who they were, what they looked like, or what they came for -- but that you were offering it to them because that was just a service of that clinic -- then there was no stigma."

CDC officials said that the average cost of an HIV test is $8 and that they expect private insurance plans as well as government health programs to cover the cost. There are different types of tests, including the traditional blood screening that is sent to a lab and a more recent oral test with results available in minutes.

Patients who test positive will be given extensive counseling and, depending on their infection, could be placed on powerful drug cocktails that cost, on average, $15,000 a year. In certain states, there are waiting lists for these drugs.

Rowena Johnston of the private AIDS research foundation amfAR, chastised federal health authorities, saying they failed to adequately describe who will cover treatment costs for patients identified through universal screening.

``We're going to be giving people this diagnosis and telling them, `By the way, even though we have life-saving medications, we can't guarantee you will get any,' " she said.

Stephen Smith can be reached at stsmith@globe.com.