LA TIMES (Thoughtlessly) Supports Routine HIV Testing For Everyone

*sigh* The Los Angeles Times continues its unfortunately ill-informed opining on AIDS/HIV policy with an op-ed in the Sunday July 23rd edition entitled "Making HIV Tests Routine." The unsigned editorial claims "[s]creening for the virus in annual physicals may be the best way to fight AIDS." In its entirety the Times piece says:

EVEN WITH ALL THAT IS KNOWN about HIV, there are still 40,000 new infections a year in the United States. One of the main reasons is that a quarter of those infected today don't know it; research shows those people are behind half of all new transmissions. Hoping to change that, the U.S. Centers for Disease Control and Prevention is expected to recommend in the next few weeks that everyone between 13 and 64 should be routinely tested for HIV, just as healthy people get regular checks of their blood pressure and cholesterol.

Though the recommendation is voluntary, doctors usually heed such federal health guidelines when suggesting preventive screenings for their patients, and insurance companies usually pay for the ensuing tests. The goal is to make HIV testing part of the typical annual physical. Since testing is now so easy — it takes as little as 20 minutes — this is doable, cheap and could do more to stem new transmissions than almost any other available option.

[...] (edited for copyright purposes)

Where to begin? First, let's stipulate that I agree that the more people who get tested for HIV is a laudable goal. This is not simply because the number of people who are aware of their HIV status will increase, but also the number of people who will get exposed to HIV prevention counselling and eventually that should reduce that stubborn rate of 40 000 new infections every year.

My main problem with the call for routine and universal HIV testing is that I am skeptical about the planning and preparation that is being done by the appropriate government, health and public policy officials for the multitudes of HIV+ individuals that will be unearthed as a result of this signifucant policy shift. Here are four questions planners should have satisfactory answers to before MadProfessah could endorse routine HIV testing for "everyone between 13 and 64."

1. Who is going to pay for the treatment of all these newly diagnosed HIV+ patients? The latest literature suggests that HIV+ individuals should start highly aggresive anti-retroviral therapy (i.e. HAART, or "the drug cocktail") immediately. The federal and state governments have not made any firm commitment to subsidize the cost of these extremely expensive medications for all people who need them and also have not done a vigorous job of negotiating wholesale price discounts on these life-saving drugs.
2. When are the HIV anti-discrimination and confidentiality protection statutes in California and other states going to be updated to handle the ramifications of a surge in the numbers of the known HIV+ population in the state and nation? The fact that it is illegal under federal law to discriminate on the basis of AIDS (or HIV status) is a judicial interpretation of the 1990 Americans with Disabilities Act (ADA), based mainly on a landmark United States Supreme Court case. In Bragdon v. Abbott an HIV+ patient sued and won a discrimination lawsuit filed against a refusal by a dentist to treat her due to her HIV+ status. However, Justice Kennedy's majority opinion's analysis depends on an interpretation that people living with HIV/AIDS must have "a physical or mental impairment that substantially limits one or more of the major life activities of such individual" in order to be covered under the anti-discrimination protections of the ADA. It's really not clear how applicable Kennedy's analysis is when there are HIV+ athletes participating in gruelling sporting events like Gay Games 2006.
   
   My feelings about the nature of the HIV confidentiality statutes in California are well-known. I am appalled that the state Legislature and Governor went along with "AIDS, Inc." to enact mandatory HIV names reporting without insuring appropriate strengthening of the relevant confidentiality (and anti-discrimination) statutes.
   
   The law needs to be updated in both these areas before I could endorse a call for universal and routine HIV testing.
3. You're HIV+, now what? There should be a well-thought out state-run program of how to deal with these newly diagnosed HIV+ individuals who will be coming from "non-traditional" (read: non gay white male) populations. There are medication issues (getting access to them, maintaining adherence, dealing with side effects), disclosure issues (who should they/do they tell, who gets automatically notified--besides the state of California and the federal government), lifestyle issues (mental health counselling, group identification/self-segregation, etc) among others which I probably can't even conceive of. I've served on the Board of Directors of an AIDS organization for four years and it's my experience which tells me that the existing AIDS service organizations are simply not ready to handle the sheer volume which would result from the universal and routine HIV testing the Times and the CDC is recommending. For example, the CDC recommends that all pregnant women who get regular pre-natal care should get an HIV test early in the pregnancy (this is because new drugs have reduced the rate of mother-child HIV transmission dramatically) but there are no particular plans in place (that I am aware of) to deal with the increase in HIV+ mothers with HIV- newborn children. Now think how the U.S. healthcare system will deal with the numbers of HIV patients which will be discovered if everyone between the age of 13 and 64 gets routinely tested?
4. Why hasn't the Ryan Comprehensive AIDS Resources Emergency (CARE) Act been reauthorized almost 9 months after it expired? As the above questions and commentary has hopefully highlighted, AIDS/HIV policy is a complicated topic. Another example of this is the current status of the Ryan White CARE Act, the single most important piece of federal legislation dealing with HIV/AIDS policy in this country. The law expired on September 30, 2005.The negotiations to reauthorize (not fully fund or increase appropriations commednsurate with demonstrated need) have been internecine. My point here is to highlight the politically fraught nature of the discussion and thus perhaps suggest the editorialists at the Times (and the bureaucrats at the Centers for Disease Control and Prevention) might be more careful before endorsing potentially life-changing public health policy for millions of Americans, which statistics indicate are likely to disproportionately Black and Brown.

Answer those questions, then get back to me!