Let’s imagine a “Hot Zone” scenario. A deadly, infectious disease is spreading through the country killing thousands a year. Most of those infecting others don't even know they carry the virus.
Then suppose that a simple, inexpensive test can identify those with the virus, get them effective treatment and drastically slow the spread of the disease.
Should the medical profession be testing as many people as possible? Of course it should.
The scenario is real. But the virus is HIV — a condition where medical logic often falters. The failure to test as widely as possible is a big reason why 40,000 Americans still get infected with HIV every year and 14,000 die from AIDS.
The Centers for Disease Control and Prevention and the New York City Health Department, along with other public health agencies, are pushing for much more HIV testing.
While there are discussions about the details, gay-rights groups and others representing people at risk for AIDS don't oppose more testing, in fact they support it. The biggest obstacle is inertia, which stems from the history of AIDS.
Old obstacles block new hope
When the test for HIV, the virus that causes AIDS, became available in 1985, there were no effective treatments. People learning they were infected were essentially hearing a death sentence. The stigma associated with AIDS was so profound that uninformed people were fearful of being in the same room with an infected person. The only tool for trying to control the spread of the disease was educating gay men and drug users, those most at risk, on how to avoid spreading the virus.
As a result of these complexities and threats to civil liberties, several states enacted laws requiring that anyone seeking an AIDS test get extensive counseling to understand the meaning of the test results and the need to avoid behaviors that put them at risk for infection. Some states, notably New York, even passed laws requiring that people can only get an AIDS test after written consent.
Nowadays, of course, anti-retroviral therapy has transformed HIV/AIDS into a chronic, manageable disease. The stigma lingers, but it is far less pronounced.
New York City Health Commissioner Thomas Frieden and others argue the danger of stigma is far outweighed by the health benefits of the test. The sooner people know of their infection and begin treatment, the less likely they will suffer complications, including death.
And at least eight studies have demonstrated that when people know they are infected, they are less than half as likely to infect others.
1 hour, $1.50, thousand of lives
In addition, testing itself has become far easier. It used to take two weeks to get back the results. Now they are available in less than an hour. A test costs about $1.50 in a public health laboratory.
Despite all these sound reasons for testing, the application of the test is still pathetic. Among the people at highest risk for HIV infection are those getting treated for gonorrhea, syphilis or other sexually transmitted diseases. But a study of health care providers in 10 hospital emergency rooms found that the providers encouraged only 10 percent of their STD patients to get tested on the spot.
They referred 35 percent to other facilities for testing without checking to find out if the patients went. The providers cited the time-consuming requirements for counseling and follow-up as the main reasons for not offering tests.
The CDC estimates that about 300,000 Americans are infected with HIV and don’t know it. It can take as long as 10 years from initial infection until symptoms of AIDS begin. But 39 percent of Americans who do test positive get their results within a year of developing AIDS symptoms, according to CDC studies. That means the virus has had up to nine years to erode their immune systems, and they have had all that time to infect others without knowing.
The solution to this mess is to make HIV testing a routine part of everyone’s medical care — as expected as a blood-sugar test for diabetes — in emergency rooms, hospitals and doctors’ offices.
No medical test should ever be mandatory. But people should be given the opportunity to “opt out” of testing rather than having to jump through hoops to get it. Counseling and education about avoiding risky behaviors should indeed continue, but it should not be linked to testing.
Many local health departments already keep lists of people who test positive, and should assure that all infected people are offered the best possible care. Those lists, despite great fears, have remained confidential with very few exceptions.
With the patient's permission, the health departments can practice “contact tracing” of sex and drug partners, determining who else a newly diagnosed person may have infected and getting those people tested and treated.
Diagnosis, treatment and contact tracing are well-established, effective tools of public health used to control outbreaks of many diseases ranging from tuberculosis to gonorrhea. As we prepare to mark the 25th anniversary of the first discovery of AIDS, in June, it is time to realize that AIDS has become another treatable contagious disease, at least in this country, and we can do a lot more to wipe it out.