Dr. 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.