Implications of universal screening for HIV infectionBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2957 (Published 08 May 2013) Cite this as: BMJ 2013;346:f2957
- Jeremy Sugarman, Harvey M Meyerhoff professor of bioethics and medicine
Universal voluntary screening of all adolescents and adults for HIV infection is now recommended by the United States Preventive Services Task Force.1 This follows similar recommendations announced by the US Centers for Disease Control in 2006.2 Although there are good reasons for endorsing universal screening, the ethical and practical implications of this approach need to be considered.
Universal voluntary screening could help identify asymptomatic people who are infected with HIV but who might otherwise go undetected until late in the course of infection. It is essential to identify such people for their own personal health and the health of others to whom they may unwittingly transmit the virus. Because of advances in the care of HIV infection, early treatment is paramount, both for individual benefit and for decreasing the likelihood of transmission. Taken together, there is a clear public health imperative to screen for this infection.3
A crucial aspect of the task force’s recommendations is that universal screening is done with notification and that patients can “opt out” of being tested. It is also recommended that before testing patients are counseled about the meaning of a positive or negative test.1 Opting out, rather than opting in, is designed to encourage uptake of testing. This approach is very different from the elaborate counseling and testing, typically accompanied by written informed consent, as required by multiple statutes across the US, which is seen by many as a barrier to testing.2 Although there were sound reasons for this practice, which was developed early in the AIDS epidemic when treatment options were limited or non-existent and HIV related stigma was widespread, now that good treatment options exist, some question its value. After all, a simpler model is akin to most routine laboratory testing.
Nevertheless, although the process for arriving at agreement to undergo HIV testing should be streamlined, the accompanying counseling is important in some circumstances. Counseling can comprise more than a discussion of the implications of test results. For example, counseling provides an opportunity for discussing ways to prevent HIV infection among those at high risk (such as pre-exposure prophylaxis) as well as safer sex practices that can help mitigate the likelihood of acquiring HIV and other sexually transmitted infections. For those who are found to be infected, counseling on the finding and its implications is crucial for ensuring physical and psychological wellbeing, especially for those who are not familiar with the implications of being infected.
Unfortunately, because proper counseling requires time and expertise, it may be difficult to implement in the clinic. With office encounters limited in time and replete with other competing priorities, clinicians will need to find efficient ways to provide patients with relevant information about the many effective methods of prevention and treatment. For example, it may help focus the conversation if patients are sent information about HIV before their appointments. In addition, because discussing HIV testing can also open the door to important questions about sexual and other risk behaviors that warrant close attention, practitioners in general clinic settings will need to develop relevant expertise in counseling on these issues.
The history of the HIV epidemic reminds us of the need for ensuring confidentiality as screening becomes widespread. In the past, just being tested could result in discrimination with regard to employment, housing, and insurance. General provisions for the privacy of medical information exist,4 and information on genetic testing has some special legal protections in the US.5 However, HIV testing does not currently benefit from such special provisions.
HIV infection remains stigmatized in some settings. The introduction of screening may reduce stigma, but in the short term patients’ concerns about stigma need to be taken seriously to ensure that they are not inadvertently harmed. Accompanying universal screening with widespread public health programs on the nature of HIV infection might help chisel away at HIV related stigma.
Part of the justification for identifying people with HIV infection rests on the safety and efficacy of current treatment approaches. Although some of those identified will have reasonable access to good treatment, it will be crucially important to ensure proper linkage to care in community settings.6 It is essential that care is made available to those who need it, and ensuring that they receive it will require sound approaches to delivering treatment.
Universal screening for HIV infection is a crucial step in helping to curb the epidemic. Knowledge about HIV status ultimately is power for those who are found to be infected. However, to achieve the goals implicit in the new recommendations for universal screening, those implementing such screening must be sensitive to the related ethical and practical challenges.
Cite this as: BMJ 2013;346:f2957
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.
Provenance and peer review: Commissioned; not externally peer reviewed.