Thursday, May 04, 2006

Routine testing for (almost) all

I should have reported on Senator Coburn's version of the Ryan White CARE Act before now. Mea culpa. However, there's been some question in my mind whether this will be the ultimate version of the legislation, so I just let Coburn do his thing (like I can "let" him)--until now. A GAO report on ADAP prices (more on which later) is associated with testimony from the GAO on that subject. The testimony also addressed the issues of testing pregnant women and, separately, partner notification. That seemed like sufficient head's up to take another look at Coburn's bill.

Technical note: Coburn's bill is S. 2339: Ryan White CARE Act Amendments of 2006 (Introduced; Feb 28, 2006). Its companion bill is: H.R. 5009: Ryan White CARE Act Amendments of 2006 (Introduced; Mar 16, 2006). Both are the same. Both have only Republican co-sponsors so far (1 in the Senate, 18 in the House).

The GAO testimony regarding the testing of pregnant women was comparatively brief--only a couple of paragraphs in 11 pages of written testimony. It touched on types of testing policies and whether states tracked the rate of pediatric infection from perinatal transmission. No serious problems, as far as I can tell, are revealed in this brief statement. However, there is some indication that some of the states surveyed do not meet standards for surveillance on this issue. That leaves the door open for Coburn's bill to switch the federal requirement from "voluntary" testing to "routine" testing.

Here's the definition of routine testing from Coburn's bill (emphasis added):

(14) ROUTINE TESTING.—The term ‘routine testing’ means HIV testing— (A) that is administered automatically to those accessing health care services for any reason; and (B) in which—(i) pre-test counseling is not required but the subject is notified that the subject will receive an HIV test and the subject may opt out of such testing; and (ii) for those individuals with a positive test result, post-test counseling, including referrals to care, is provided and confidentiality is protected.
And here I thought he was talking about changing the requirement for pregnant women! Silly me. This is universal testing.

Here's the relevant passage of the bill:

(1) IN GENERAL.—Except as provided in paragraph (2), the Secretary shall require rapid routine testing of each client at any health facility, provider, clinic, or entity (including an HIV, STD, or substance abuse clinic) receiving funding from the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration, the Health Resources and Services Administration, the Centers for Medicare & Medicaid Services, or any reproductive health program administered by the Secretary.

(2) EXCEPTION.—Rapid routine testing shall not be required in the case of an individual who has already been diagnosed with HIV infection.

One would love to see the fiscal note on this, especially for "entities" that receive funds from Medicare and Medicaid.

Cynicism aside, it's worth considering Coburn's motivations. Coburn is a physician. When push comes to shove, he can overcome his (incredibly) conservative ideology and stick to the science, if only for a brief moment. In this instance, he appears to be looking to the science of public health and trying to steer the nation toward the routine testing that would become virtual screening. Once you've screened, you can treat those infected, counsel those at risk, and, if it all works as planned, slow down or halt the epidemic.

The facts on the ground suggest that he is not completely off base. One, the epidemic continues to grow, to a large extent, because people who do not know their HIV status are unknowingly transmitting the virus. Two, misperceptions about who is at risk for HIV lead some to feel safer in engaging in high risk behaviors because they "are not at risk," i.e., they are not gay, not using heroin, etc. Three, poverty is increasingly being cited as a “risk factor” for HIV infection. Four, identification of infection is important for the individual (treatment) and society (prevention).

But--there's always a but--routine testing, while voluntary, sometimes becomes mandatory testing when it is improperly handled, i.e., if people are not informed prior to the test that (a) they will be tested and (b) they have the right to opt out. Mandatory testing tends to drive people away from whatever system is mandating the testing. This avoidance is directly related to porous confidentiality in the health care system and the continued stigma associated with HIV/AIDS in the broader community.

Part of me thinks that the science of public health should prevail. Part of me worries about the unintended consequences of this policy. Part of me just doesn't trust Tom Coburn.

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