Rapid responses are electronic comments to the editor. They enable our users
to debate issues raised in articles published on bmj.com. A rapid response
is first posted online. If you need the URL (web address) of an individual
response, simply click on the response headline and copy the URL from the
browser window. A proportion of responses will, after editing, be published
online and in the print journal as letters, which are indexed in PubMed.
Rapid responses are not indexed in PubMed and they are not journal articles.
The BMJ reserves the right to remove responses which are being
wilfully misrepresented as published articles or when it is brought to our
attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not
including references and author details. We will no longer post responses
that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
The news article published by Edward Davies describes the need for a mandatory HIV test amongst US citizens. The article comments upon some of the reasons behind this recommendation, including: low public awareness of personal risk, poor communication and discussion by health professionals, and also the benefits of earlier treatment for those infected and previously unaware. However, the disadvantages and potential ethical dilemmas associated with such a scheme are not addressed. Given the privatised nature of the health system in the US, the issue at the forefront of my mind when I consider this issue is the matter of health insurance.
Currently, 15% of the US population has no health insurance [1]; a significant proportion that is unevenly distributed, with the majority of the uninsured being from poorer socio-economic backgrounds. This issue, coupled with the fact that HIV infection rates are also more prevalent in those from poorer backgrounds raises the concern that if mandatory testing was made federal policy, more people from lower socio-economic groups would be refused health insurance or else faced with rising premiums.
One of the main financial aids for HIV patients is the Ryan White Programme, which currently provides HIV care to over half a million US citizens who would otherwise not have sufficient funds themselves [2], equating to roughly half of all those infected with HIV in the US. This programme funds both access to key pharmaceuticals and healthcare and currently receives $2.1 billion per year in federal funding [2]. If HIV testing did become mandatory, how would this funding keep up with the 24,000 people thought to be living with HIV but unaware of their status - and more likely to be from poorer socio-economic backgrounds? [3].
In addition to this, around 55% of emergency healthcare insurance costs are never reimbursed due to policy shortcomings [1]. I feel that this issue further compounds the overall problem when one considers that HIV, with its associated wide range of opportunistic infections may also cause a higher rate of admissions via A&E [4]. With this in mind I make the case that potentially, a diagnosis of HIV due to mandatory testing and with the US health system in its current form, may preclude many vulnerable individuals from receiving the care they need by exposing them to public and private-sector stigma. The ethical concept of utilitarianism is the most pragmatic approach in this situation. Therefore I would ask you to consider if, currently, utility of resources dictates that more HIV patients may indeed benefit from increased funding and provision than would benefit from knowing their status but being impeded from the care they need.
1.HIV and AIDS: Treatment in the United States of America. AVERT International HIV and AIDS charity. Last updated 2012. Available from:http://www.avert.org/aids-treatment-america.htm#contentTable1
2.About the Ryan White HIV/AIDS Programme. HRSA online. Last updated 2012. Available from: http://hab.hrsa.gov/abouthab/aboutprogram.html
3.United States of America HIV/AIDS statistics. AVERT International HIV and AIDS charity. Last updated 2012. Available from: http://www.avert.org/usa-statistics.htm
4.Mor V, Fleishman JA, Dresser M, Piette J. Variation in Health Service Use Among HIV-Infected Patients. Medical Care (1992), 30(1): 17-29
Competing interests:
No competing interests
18 December 2012
Jennifer Hanks
4th year Medical Student
Nicholas D. Gollop, Academic FY1 Doctor, Norfolk and Norwich University Hospital.
Re: Test all adults aged 15 to 65 for HIV, recommends task force
The news article published by Edward Davies describes the need for a mandatory HIV test amongst US citizens. The article comments upon some of the reasons behind this recommendation, including: low public awareness of personal risk, poor communication and discussion by health professionals, and also the benefits of earlier treatment for those infected and previously unaware. However, the disadvantages and potential ethical dilemmas associated with such a scheme are not addressed. Given the privatised nature of the health system in the US, the issue at the forefront of my mind when I consider this issue is the matter of health insurance.
Currently, 15% of the US population has no health insurance [1]; a significant proportion that is unevenly distributed, with the majority of the uninsured being from poorer socio-economic backgrounds. This issue, coupled with the fact that HIV infection rates are also more prevalent in those from poorer backgrounds raises the concern that if mandatory testing was made federal policy, more people from lower socio-economic groups would be refused health insurance or else faced with rising premiums.
One of the main financial aids for HIV patients is the Ryan White Programme, which currently provides HIV care to over half a million US citizens who would otherwise not have sufficient funds themselves [2], equating to roughly half of all those infected with HIV in the US. This programme funds both access to key pharmaceuticals and healthcare and currently receives $2.1 billion per year in federal funding [2]. If HIV testing did become mandatory, how would this funding keep up with the 24,000 people thought to be living with HIV but unaware of their status - and more likely to be from poorer socio-economic backgrounds? [3].
In addition to this, around 55% of emergency healthcare insurance costs are never reimbursed due to policy shortcomings [1]. I feel that this issue further compounds the overall problem when one considers that HIV, with its associated wide range of opportunistic infections may also cause a higher rate of admissions via A&E [4]. With this in mind I make the case that potentially, a diagnosis of HIV due to mandatory testing and with the US health system in its current form, may preclude many vulnerable individuals from receiving the care they need by exposing them to public and private-sector stigma. The ethical concept of utilitarianism is the most pragmatic approach in this situation. Therefore I would ask you to consider if, currently, utility of resources dictates that more HIV patients may indeed benefit from increased funding and provision than would benefit from knowing their status but being impeded from the care they need.
1.HIV and AIDS: Treatment in the United States of America. AVERT International HIV and AIDS charity. Last updated 2012. Available from:http://www.avert.org/aids-treatment-america.htm#contentTable1
2.About the Ryan White HIV/AIDS Programme. HRSA online. Last updated 2012. Available from: http://hab.hrsa.gov/abouthab/aboutprogram.html
3.United States of America HIV/AIDS statistics. AVERT International HIV and AIDS charity. Last updated 2012. Available from: http://www.avert.org/usa-statistics.htm
4.Mor V, Fleishman JA, Dresser M, Piette J. Variation in Health Service Use Among HIV-Infected Patients. Medical Care (1992), 30(1): 17-29
Competing interests: No competing interests