CDC says it should reduce transmission, ease stigma

Testing for the AIDS virus could become part of routine physical exams for adults and teens if doctors follow new U.S. guidelines expected to be issued by this summer.

Federal health officials say they'd like HIV testing to be as common as a cholesterol check.

The guidelines for routine testing would apply to every American ages 13 to 64 under the proposal by the Centers for Disease Control and Prevention.

One-quarter of the 1 million Americans with the AIDS virus don't know they are infected, and that group is most responsible for HIV's spread, CDC officials said.

In King County, the same estimate holds true -- about one-quarter of the 8,400 people living with HIV are unaware of their condition, according to public health officials.

"We need to expand access to HIV testing dramatically by making it a routine part of medical care," said the CDC's Dr. Kevin Fenton.

The recommendations would not be legally binding, but they would influence what doctors do and what health insurance programs cover.

The CDC already recommends routine testing for those at high risk for catching the virus, such as intravenous drug users and gay men, and for hospitals and certain other institutions serving areas where HIV is common. It also recommends testing for all pregnant women.

Under the new guidelines, patients would be tested for HIV as part of a standard battery of tests they receive when they go for urgent or emergency care, or even during a routine physical.

Patients wouldn't get tested every year. Repeated, annual testing would be recommended only for those at high risk.

There would be no consent form specifically for the HIV test; it would be covered in a clinic or hospital's standard care consent form. Patients would be allowed to decline the testing.

Standardizing HIV testing should reduce the stigma as well as transmission, CDC officials said. Nearly half of new HIV infections are discovered when doctors are trying to diagnose an illness in a patient who has come for care, they noted.

Dr. Patrizia Showell, an internist at the Polyclinic in Seattle, said the new recommendations will make it easier to talk to some patients about HIV and AIDS testing.

"You can say it's recommended now. It's not something strange and unusual," said Showell.

Patients tend to shy away from testing if it means they'll have to discuss their sex or drug habits with their physician, said Dr. Hunter Handsfield, former head of King County's STD Control Program.

"Studies now show when you make testing dependent on asking about risk ... it intimidates people from asking at all," said Handsfield, who helped craft an early version of the CDC recommendations.

Making the test routine also reinforces the fact that HIV and AIDS isn't just something for people at high risk to worry about, said Dr. Damon McBrinn, a family medicine specialist at the Swedish Physicians clinic on Queen Anne.

"(The recommendation) may be useful to increase the reality that this is something you potentially are at risk for," said McBrinn.

But for some parents, that may be an uncomfortable reality.

"I would not voluntarily let my kids do that between 13 and 18," said Rob Philbrick, a father of three who lives on Mercer Island.

However, in Washington, children 14 and older don't need their parents' consent to be tested for sexually transmitted diseases, including HIV, said John Peppert, manager of the HIV prevention section at the state Department of Health.

Among those most likely not to know they are HIV-positive until after they've developed symptoms of AIDS are African Americans, Hispanics, people who are heterosexual and those between the ages of 18 and 29.

While undiagnosed infected people represent only about 25 percent of Americans now living with HIV, they are believed to be responsible for more than half of the 40,000 new infections each year, said Dr. Tim Mastro, acting director of the CDC's Divisions of HIV/AIDS Prevention.

The CDC's proposed guidelines conflict, however, with those issued last July by the U.S. Preventive Services Task Force, the nation's leading independent panel of private-sector experts on prevention and primary care.

That group, sponsored by the U.S. Agency for Healthcare Research and Quality, found there wasn't enough evidence to recommend for or against routine HIV screening. The task force's recommendations are what the nation's health insurers generally look to when deciding coverage issues, and are influential with family physicians.

Dr. Bruce Calonge, task force chairman, said his group looks at the state of the scientific evidence to decide if actions have documented benefits -- and it's not there for universal screening.

Some patient advocates have voiced concern that the recommendations do not include pretest counseling and sufficient informed consent.

At many HIV testing sites, patients sit through a counseling session to explain the procedure before blood is drawn. Many centers also require patients to give "informed consent," indicating they understand the risks and benefits of the test.

"Finding out you have HIV is significant," said Fred Swanson, executive director of Gay City Health Project, which offers HIV/AIDS testing on Capitol Hill. "You want to know you're being tested in an environment where people are trained to help you take the next step."

Routine testing also raises the question of who will pay.

It's unclear whether Medicare or private insurers would agree to pay for thousands of routine HIV tests. In general Medicare is not authorized to pay for routine screening tests unless specifically authorized by Congress.

Private insurers are studying the proposal, said Susan Pisano, spokeswoman for America's Health Insurance Plans, which represents them.

"Generally speaking our member companies follow recommendations of the U.S. Preventive Services Task Force," she said.

Public health clinics and community testing sites, such as Gay City, offer testing free or at a reduced charge for people who can't afford it. But some of those tested at their regular doctor's office will likely pay out of pocket.

Unlike mammograms and cervical cancer screenings, insurers are not required by state law to cover HIV testing, said Beth Berendt, deputy insurance commissioner for Washington.

"If I'm an otherwise healthy 50-year-old female going in for a physical exam and the doctor says I'm going to run an HIV test, the chances are the health plan would not cover it," said Berendt. "It would be a new level of screening that is not required by state law."

McBrinn, the Swedish family medicine doctor, said some of his patients opt to be tested at clinics where their anonymous records can't be accessed by insurance companies. They worry, he said, that frequent testing could raise a red flag for life insurance companies about high-risk behavior.

"This kind of a policy would be useful to normalize testing," McBrinn said.

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P-I STAFF AND NEWS SERVICES

The Associated Press, Cox News Service and P-I reporters Julie Davidow and Susan Phinney contributed to this report.

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