U.S. Urges H.I.V. Tests for Adults and Teenagers
By DONALD G. McNEIL Jr.
Published: September 22, 2006
In a major shift of policy, the federal government recommended yesterday
that all teenagers and most adults have H.I.V. tests as part of routine
medical care because too many Americans infected with the AIDS virus don’t
The recommendation, by the Centers for Disease Control and Prevention, urges
testing at least once for everyone aged 13 to 64 and annual tests for those
with high-risk behavior.
The proposal is a sharp break from the early days of the AIDS epidemic, when
the stigma of the disease and the fear of social ostracism caused many
people to avoid being tested.
That led to heated debate about whether positive test results could be
shared by medical and governmental authorities in their effort to contain
the epidemic by reaching out to partners of those who might be infected.
Under the agency’s plan, which states can adopt or modify if they choose,
patients would be advised they were being tested, but the tests would be
So that the tests could be easily administered, however, the agency urged
the removal of two major barriers that some states now have: separate signed
consent forms and lengthy counseling before each test.
That would require new laws in some states, however, which could take years
because some civil liberties groups and lobbyists for people with AIDS
oppose the changes.
Many doctors are expected to welcome the changes.
“These recommendations are important for early diagnosis and to reduce the
stigma still associated with H.I.V. testing,” said Dr. Nancy Nielsen, a
board member of the American Medical Association, which endorsed the new
Dr. Julie Gerberding, the disease control agency’s director and a doctor who
treated some of the first San Francisco AIDS patients in 1981, said: “Our
traditional approaches have not been successful. People who don’t know their
own H.I.V. status account for 50 to 70 percent of all new infections. If
they knew, they would take steps to protect themselves and their partners.”
The new guidelines, if adopted, would move the agency toward its “ultimate
goals,” which Dr. Gerberding described as: no more H.I.V.-infected children,
no one living for years without antiretroviral treatment and, eventually, no
more new cases of the disease.
About 40,000 Americans are newly infected each year, a number that has been
remaining steady. In contrast to the early days of the epidemic, which
struck gay men the hardest, many of those now infected are black or
Hispanic, are teenagers and were infected by heterosexual sex. The agency
estimates that 250,000 Americans, a quarter of those with the disease, do
not know they are infected.
Moreover, 42 percent of those who find out they are infected are tested only
because they are already seriously ill — which means they have been infected
for up to 10 years and may have been passing the infection on all that time,
Dr. Gerberding said.
The American Academy of H.I.V. Medicine, a group for AIDS specialists, gave
a qualified endorsement of the guidelines, agreeing with the need for more
testing but arguing that they gave counseling short shrift.
“Counseling just naturally goes with testing, as diet does to exercise,”
said Dr. Jeff Schouten, the academy’s chairman.
Some civil liberties organizations and those representing people with AIDS,
while favoring more testing, have lobbied against removing signed consent
forms or pretest counseling for fear that such changes will make testing
Some states, including New York, have laws requiring such counseling and
consent forms. They were passed in the early days of the AIDS epidemic, when
having the virus amounted to a death sentence, the disease’s stigma often
led to denial of jobs or housing, and testing was done primarily to protect
the blood supply.
Dr. Thomas R. Frieden, New York City’s health commissioner, said yesterday
that he “absolutely” agreed with the new guidelines and had been lobbying
the state Legislature for a law incorporating them.
A bill he supported was introduced late last year, Dr. Frieden said, but
opponents kept it from coming up for a vote.
“I am optimistic that it will make it through this year,” he said.
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.”
David Ernesto Munar, associate director of the AIDS Foundation of Chicago
and a board member of the National Association of People With AIDS, said he
favored more testing and faster counseling to encourage it.
“But our fear,” Dr. Munar said, “is that on the ground, the rush to get more
blood samples is going to railroad right over any consent.”
Illinois, like New York, requires written consent before a test, he said.
Disease control agency experts deny that their guidelines would encourage
They oppose mandatory testing, secret testing or testing without informing
patients, at least orally, that such a test will be done. They suggest that
whatever general consent for routine medical care a state law requires
include consent for H.I.V. testing.
They also want anyone who tests positive to be counseled that AIDS is a
serious disease and taught where to get treatment and how to keep from
As an example of success in a related program, Dr. Timothy Mastro, acting
director of the agency’s AIDS prevention division, pointed to the agency’s
guidelines to prevent infection of newborns.
The guidelines say that all pregnant women should be tested unless they
refuse and that oral consent is acceptable. They also recommend tests again
in late pregnancy for women who inject drugs, have sex with many men, have
sex for money or live in neighborhoods where AIDS is common.
The number of babies born infected dropped to fewer than 240 a year now from
1,650 in 1991, Dr. Mastro said.
Laws for prisoners, which Dr. Mastro described as “a tricky area,” might
also need revision. In some states, testing is mandatory for all prisoners.
In New York, it is voluntary.
Health officials in other states appeared to welcome the new guidelines.
Steve Huard, spokesman for the Hillsborough County Health Department, which
includes Tampa, Fla., said: “We strongly believe in universal H.I.V. testing
through anonymous and confidential testing. With the recommendations, it
would be more widespread. It would go out to private physicians and we
should see infection rates going down.”
Some states with few AIDS patients, like Wyoming, may be reluctant to adopt
the guidelines on the ground that routine H.I.V. tests would be
unnecessarily burdensome for doctors and patients.
To compensate for that, the guidelines suggest that routine tests might not
be required in areas where fewer than 1 in 1,000 people test positive. But
health care practitioners are not very good at guessing what rate will be
found among their patients, said Dr. Bernard Branson, the C.D.C.’s associate
director for laboratory diagnostics, so there should first be a period of
The wholesale cost is about $1 for each test run in batches and about $8 for
rapid tests done individually. Each positive test would require a second
confirmation test and then counseling, which would raise the cost to about
$80, Dr. Branson said.
That is far cheaper than many other routine screening tests like
colonoscopies or mammograms, and Dr. Branson said most such tests were paid
for by insurers because it was usually cheaper to treat diseases when they
were caught early.