amfAR, The Foundation for AIDS Research

The Ethics of New HIV Testing Methods

By Jeffrey Laurence, M.D.

Merchant RolandDr. Roland MerchantOver the past decade the methods by which one can test for antibodies to HIV, a sign—unless you’ve participated in an experimental AIDS vaccine trial—of an active infection, have evolved markedly. But accompanying each step forward in terms of access, cost, and rapidity of results have been ethical concerns. amfAR grantee Dr. Roland Merchant of Brown University and colleagues, including former amfAR Board member Dr. Kenneth Mayer, highlight how patient and physician perspectives differ on one major change to recommended HIV testing methods.

Writing in the May-June issue of Public Health Reports, Dr. Merchant and associates from the departments of Emergency Medicine, Community Health, and Medicine at Brown summarize a survey they conducted of 249 physicians, physician assistants, and nurse practitioners and 1,013 of their patients. The survey questionnaire focused on the 2006 Centers for Disease Control and Prevention (CDC) recommendations promoting a universal approach to HIV testing. These guidelines suggest that everyone in a health care setting, regardless of perceived risk for HIV infection, should be offered the test unless they “opt out,” or refuse it. Only a general medical consent is required, rather than an HIV specific one, and prevention counseling is optional. All of this could increase HIV testing and linkage to care, and decrease the burden on health care staff in implementing such testing.

Some leaders in HIV care and advocacy were concerned that patients may not be fully informed by such a rapid approach, might be tested without full consent, and would lose opportunities for prevention counseling. Indeed, many states with large numbers of HIV-infected individuals, including New York, do not use these new CDC guidelines, favoring the more stringent 2001 standards.

The researchers found that physicians and other health care workers differed from patients on their perspectives about whether the new CDC methods were “morally acceptable.” The clinicians were much more conservative, believing they were inferior to the original guidelines for eight of the nine criteria examined. In contrast, patients found the new methods to be inferior in only three of the nine categories, including “less likely to reduce HIV risk behaviors,” and “reduced understanding of consequences of test results disclosure.” Clinician preference was highest for mandatory HIV prevention counseling. Both doctors and patients agreed that the new “opt-out” approach was more likely to destigmatize HIV testing.

Merchant and associates concluded that, “If patients are not convinced about the merits of the recommended methods, and clinicians have ethical concerns about them, then the hope for their implementation might not be fully realized. As a consequence, the subsequent increase in HIV testing with resultant increase in linkage to care and reduction in HIV transmission [the aim of these new CDC guidelines] might not be fully realized.”

Dr. Laurence is amfAR’s senior scientific consultant.