President Barack Obama is unveiling a new National AIDS Strategy this week, and the plan calls for more emphasis on HIV antibody testing. Surprise, surprise.
As those of us who work in the HIV prevention field know, increased testing efforts is not new at all. The U.S. Centers for Disease Control and Prevention has been pushing routine HIV testing for years. The idea is that HIV testing should be included in a battery of tests performed during a routine physical. The CDC, along with many in the HIV prevention arena, believe that HIV testing should be very routine. Though not many people are publicly saying that testing should be required, many within the CDC believe that we should make an effort to screen everyone — as in every American.
This is a deeply flawed approach. Attempting to test every American for HIV would be too costly, and more importantly, it would not lead to discovering a significant number of new infections. And while routine HIV testing sounds good in theory, in practice, it makes no sense either.
Unlike cancer or diabetes, HIV is a virus that is acquired through certain behavior. While I might be more likely to get diabetes because it runs in my family, my risks for HIV are not increased if my parents both died of AIDS. I can only catch HIV by explicitly doing something to acquire it, like sharing needles or having unprotected sex. Testing everybody, regardless of their risk factors, is unwise because it wastes too much time and effort on those who aren’t at risk. Since we have limited resources and limited manpower, it makes more sense to focus prevention efforts on people who are at the highest risk for transmission. By focusing on people at the highest risk for transmission, we are more likely to discover new infections. If I were looking for oral cavities it’s much more likely that I would find them in people who eat lots of candy than in people who never eat candy and brush their teeth three times a day.
Routine HIV testing is another grand idea that only works in theory. HIV testing, and the risk reduction counseling that goes along with it, should always be client-centered. This means that each testing event is approached from the perspective of what’s in the best interest of the person being tested. Under this construct, no two HIV testing sessions are ever the same; and it would be impossible to predetermine any aspect of the session itself. For example, a client-centered approach would not assume anything about the client in advance; so it would be client-centered to not test a client for HIV if no risk factors were discovered.
By making HIV testing a routine part of health care, it invites lazy care from doctors. If HIV testing is routine, then doctors won’t need to talk to their patients about risks, they will simply give them the test and check off a box on a form. This is not client-centered; this is health care system-centered. It would be much better if doctors actually spent time talking to patients, getting to know them more closely, and recommending what tests they should take based on individual need. Routine testing also assumes that people see a physician routinely; this concept becomes even more flawed when you consider the number of people who never see a doctor. Studies show that the people who don’t have routine medical care are the very people at the highest risk for HIV. And let’s not leap to the conclusion that health care reform equals more people taking advantage of health care. Cultural norms, fear and stigma will still prevent some people from seeking health care even when it’s free or largely subsidized.
I know people who advocate for routine and/or universal HIV testing are well-intentioned; some of these people are my colleagues and friends. And you can’t fault good people for trying to help others learn their HIV status, which certainly leads to healthier communities and fewer new infections. But these blanket efforts to test the masses is misguided and lazy. It’s hard work to seek out and test the people who need HIV testing the most, but that is the calling of this generation of AIDS activists. And no matter how routine the test or how readily available it is, we must convince people it is within their best interest to know their status and to protect their communities.