HIV screening: Just another routine test?
The CDC and the World Health Organization have recently made sweeping changes to their guidelines regarding HIV screening. The primary thrust of these revisions is to institute programs that will increase the number of individuals who are aware of their HIV status by decreasing the requirements for extensive counseling and adding opt-out policies. According to the opt-out policies, the test is performed unless the client specifically declines it. The opt-out portion of these new standards for HIV testing represents a complete reversal of earlier practices and has significantly improved screening rates among patients (J Gen Intern Med. 2008; 23:800-807).
I think that as clinicians, many of us have struggled over the years in the area of HIV screening. Under extreme circumstances, when patients present with risk factors such as IV drug use, very unsafe sexual practices, or high numbers of sexual partners, the job is easy. With less obvious clues, however, it's a considerably more difficult task. I'm sure we've all had patients tell us, “I'm really not at risk.” Let's face it, though: Who has absolutely no risk? In my own 15-year career I have diagnosed as positive 11 women who believed they were in monogamous relationships but whose husbands had been engaging in extramarital high-risk sex.
Despite our current testing efforts, we continue to see cases identified in the later stages of infection (AIDS Care. 2008; Nov 24:1-10 [published online ahead of print]). Such cases are less amenable to treatment and result in an extremely high viral burden, which makes the transmission of the virus far more likely in those who are unknowingly engaging in unsafe sex.
All of this raises the question: Why is HIV testing so different from other types of routine screening that we perform? One might argue that HIV screening relates to the sexual connotations of the disease. If this is the case, why is routine screening for cervical cancer, which is caused by the sexually transmitted human papillomavirus (HPV), so well received? Despite our best efforts, our society attaches a stigma to HIV disease (AIDS Care. 2009;21:87-93). Furthermore, research indicates that health-care workers often stigmatize these patients (AIDS Patient Care STDs. 2008;22:669-675).
So in truth, HIV infection is not an equal-opportunity disease. People tend to display empathy for a cancer patient, yet while people certainly empathize with HIV sufferers, there is always the question of how the person acquired the infection. The fear of this element of the disease, coupled with misperceptions regarding HIV-related risk factors, is the crux of the problem. And the fear of being designated a bad person as a result of being infected, along with the profound lack of awareness regarding perceived risk by many, does not bode well for universal screening.
So what can we do as health-care providers? Normalize the disease by talking about it just as we'd talk about any other. When patients ask me if I think they're at risk, my answer always starts with the question, “Have you ever had sex?” I then explain that they are not likely at high risk, but risk is risk. HIV has been designated a chronic disease, and like other chronic diseases, we screen for it and initiate treatment early. I emphasize the fact that like most of the tests we do, HIV screening is negative most of the time. I have delivered far more negative than positive test results, as is likely the case for all of you. For patients, knowing they're negative—rather than simply hoping—relieves stress and reinforces safe behavior.