CDC to change HIV test guidelines
CDC to change HIV test guidelines
In recognition of some of the challenges noted by ED managers regarding HIV testing, the Centers for Disease Control and Prevention is modifying its guidelines for HIV screening and testing in medical facilities. The new guidelines, which are out for comment, would make HIV testing a standard part of medical care in all health care settings, including the ED. They include the following:
- The screening of every person 13-64, regardless of risk or prevalence. (Repeat testing would only be recommended for those at high risk).
- Testing should be part of a general battery of tests. There would be no need for separate consent for HIV testing.
- Counseling services should be focused on those who test positive. Pretest counseling would not be a requirement.
"A big part of the reason for these proposed changes is that we recognized as we looked at surveys [of providers] that the requirements of counseling and informed consent were serving as barriers," notes Bernard Branson, MD, the CDC's associate director for laboratory diagnostics, Division of HIV/AIDS Prevention, and one of the authors of the proposed guidelines. They were in place to protect patients when there was not much information available, Branson says. "Those things have now become counterproductive, so we have new recommendations — and have in fact split off health care settings from other kinds of testing settings," he says.
He adds that demonstration projects conducted in several EDs by the CDC indicate that even the concern about follow-up can be overcome. "The recommendations essentially call for a continuum care, but what we have shown in demonstration projects is that when they did rapid testing, most EDs worked out an arrangement for an AIDS clinic where the patient could go to get confirmatory results, so the ED will not have to undertake it," Branson explains. Many ED managers complain that they don't have the staff or the time to follow up with all patients after HIV testing.
He points to one of the projects, at Alameda County Medical Center in Oakland, CA, where the triage nurse offered testing to everyone who came to the ED. "Using an oral fluid rapid HIV test, the nurse offers the test, conducts it, and interprets the result," says Branson. The ED has a guaranteed drop-in appointment slot at a clinic, so when they test someone as positive, they can automatically put them into that slot.
While these new guidelines, set to be finalized this summer, may sound like the ultimate solution to the problem, emergency medicine experts remain skeptical. First, they note, rapid testing still is subject to erroneous results. In addition, state regulations often can be in conflict with the CDC guidelines. For example, regardless of the process the ED would prefer, "Most states require pre- and post-testing," notes David Gurr, MD, associate director for emergency services at Jackson Memorial Hospital in Miami. "In Florida, for example, the state requires that you do the follow-up on any test you order."
Branson concedes this requirement could be an obstacle. The model the CDC proposes is the one in Texas. "They have an ideal informed consent policy," he says. "In a medical care setting, when a person has signed the form for a medical exam and testing, there are no additional requirements, so you don't have to jump through that extra hoop."
The new guidelines also would not solve the problem of the high cost of testing. "Since we recommend testing across the board, we anticipate the tests will be reimbursable if the patient is covered by Medicare or Medicaid," says Branson, "But there will need to be public funds."
Sources
For more information on the Center for Disease Control and Prevention's HIV testing policy, contact:
- Bernard Branson, MD, Associate Director for Laboratory Diagnostics, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta. E-mail: [email protected].
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