December 1st was World AIDS Day, and we should all celebrate the fact that we've come a long way since the days when an HIV diagnosis was essentially a death sentence.
Between dogged advocacy, persistent scientific investigation, and widespread opportunities for treatment, the number of people dying of AIDS in this country continues to decline. Unfortunately the number of people living with HIV in some places continues - stubbornly - to rise.
More alarming - many Americans do not know their HIV status, despite the many different places people can go to get tested. And then there are the complications that could result from, or compound, an HIV diagnosis, such as Hepatitis C. But that's a discussion for another day.
Prince George's County experienced a steady increase in the number of residents living with both HIV and AIDS in the 2000's with zip codes 20743 and 20785 experiencing the highest rates of infection in 2010. At the same time, however, the county reported declining death rates from HIV/AIDS 2006-2012.
So if 1 in 7 Americans are living with HIV and do not know it, and worse, are unknowingly transmitting the disease to others, is it time for mandatory testing, at least for the most sexually active populations?
The U.S. Preventive Services Task Force recommends that clinicians screen for HIV among adolescents and adults aged 15-65 years of age. They also recommend screening all pregnant women, especially for those in labor whose status is unknown. But again, a recommendation is not a mandate.
A mandate would run into consent, privacy and stigma issues, such as what happens if I choose not to obey the mandate? What would be the penalty? If I comply, "will my business be out in the street"? Will I face social stigmatization, or will my insurance premiums go up? How will this affect my sex life? Will I now have to contact all previous partners to advise them of this? Would they want to know? Will I find out who infected me? Do I really want to know that?
For those who willingly comply or are coerced into the testing - will a positive diagnosis open doors for all the treatment and care needed?
HIV tests are now specific and sensitive enough that false positives are a negligible worry, but what to do about the inevitable increase in false positives if more people get tested? And who will coordinate the care for those found positive but are uninsured? We note the millions in the Deep South who are uninsured, and poor, and at high risk for contracting HIV, but their governors chose not to expand Medicaid and they don't qualify for ACA coverage on the federal exchange. Who would pay for, or coordinate, their care if they come up positive in a mandatory HIV test?
There are obviously no easy answers here. The standard should be that clinicians become comfortable with having this conversation during the clinical encounter, so that patients can be, in a culturally appropriate way, encouraged to find out their status and take appropriate action. This is especially true among high-risk populations.
Patients also need to be able to answer the 'then what?' question, They need to know there is adequate support throughout the journey, and that they won't go bankrupt or be ostracized along the way.
The policy levers are straightforward. Continue - and ramp up - the public health education and awareness, especially among high-risk populations. Train all clinicians and potential caregivers in how to talk about this in a culturally appropriate manner. Adequately fund education, prevention, diagnosis, treatment, and research. Repeat. Over and over. Until HIV/AIDS is like a nightmare from which we have now awakened.
