Monday, May 08, 2006

More on routine testing

We wrote about Senator Tom Coburn's version of the Ryan White CARE Act and its somewhat obscure provision for routine testing for anyone who accesses the health care system recently with more than a touch of skepticism. In tracking down references for another article, I found this:

Risk-Based Human Immunodeficiency Virus (HIV) Testing Fails to Detect the Majority of HIV-Infected Persons in Medical Care Settings.
Sexually Transmitted Diseases. 33(5):329-333, May 2006.
Jenkins, Timothy C. MD; Gardner, Edward M. MD; Thrun, Mark W. MD; Cohn, David L. MD; Burman, William J. MD

The authors' conclusions are fairly straightforward:
Although one-third of newly diagnosed HIV-infected patients had clinical visits in the 3 years before diagnosis, few presented with clinical conditions typically associated with HIV infection. Targeted testing based on clinical presentations is not likely to result in substantially earlier HIV diagnosis. Routine screening in high prevalence settings could be more effective.

Some folks in the study actually presented with risk factors or clinical indicators of HIV infection, but were not tested. Many more showed no such signs. Routine testing--rather than better training of health care personnel to recognize risk factors and clinical indicators--would have benefited them all, giving them earlier access to treatment and helping in preventing transmission to any sex partners that they may have had subsequent to their encounter with the health care system.

The niggling doubt that I have, however, comes from (admittedly) anecdotal reports from a major Texas public hospital. What I hear is that the Texas policy of routine testing of pregnant women is being abused. Women are tested without being informed that the test is voluntary and they may choose not to be tested.

Texas statute requires that women be given "printed educational materials" at the point where they would be tested (first prenatal visit and delivery). The "printed educational materials" that the Department of State Health Services makes available is this flyer, which is also available in Spanish. The flyer is, however, no longer printed by DSHS. Providers must download it and print it themselves for their patients. A call to DSHS nets the information that there is no information about the extent to which this flyer, written some years ago, is still being used by providers to educate their patients.

None of this is particularly useful in analyzing the issue of routine testing. The concept makes sense. Research appears to support it. The opt out provision is important from a civil liberties point of view, but public health concerns may be strong enough to override that issue. What remains is the porosity of confidentiality in the health care system, which matters because of the continuing stigma against people living with HIV/AIDS. That stigma kills--personal relationships, community support, economic opportunity, hope.

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