HIV counseling and testing: less targeting, more testing.

American Journal of Public Health | June 2006, Vol 96, No. 6 962 | Editorials HIV Counseling and Testing: Less Targeting, More Testing Approximately 25% of persons infected with HIV nationwide remain undiagnosed. Identifying these individuals represents the biggest challenge for HIV control in the United States. More timely diagnosis of HIV can improve treatment and care of those infected with HIV, prolong survival, and reduce the spread of HIV. The impact of these late testers on the dynamics of the epidemic is well characterized by the number of persons who are identified with HIV only when they have progressed to AIDS. Each year, more than 1000 New York City residents—3 per day— are diagnosed with concurrent HIV and AIDS, and nationally 40% of new diagnoses are concurrent. Many of these late testers have been infected for 10 years or longer, unknowingly exposing their partners to HIV. Indeed, most HIV infections are transmitted by people who are unaware of their status. Thus, despite substantial progress in HIV treatment and prevention of maternal–child transmission, little progress has been made in identifying the reservoir of those infected and unaware of their serostatus. We propose that the largest barrier to advancement of this central goal is a continued reliance on a single HIV counseling and testing model. Ironically, the system initially put into place to protect the rights and safety of individuals has now become an impediment to the public health control of HIV. Laws governing HIV testing were developed at a time when the infection was untreatable and intensely stigmatizing. As a result, a very cautious approach to testing was adopted from the genetic-counseling model of testing for untreatable conditions. Yet, even though the HIV epidemic has not remained static, the testing process has, having not changed appreciably since the introduction of the ELISA and Western blot in 1985. Legislation continues to mandate lengthy pretest counseling that varies state to state and by funding stream. A separate written informed consent is still a requirement in more than a dozen states including New York, home to 1 in 6 persons living with HIV. The imposition of these extra steps has prevented HIV testing from becoming a routine part of medical care resulting in numerous missed opportunities to diagnose, treat, and stop the spread of HIV. We advocate for standardization of verbal informed consent and shifting resources from mandated pretest counseling to effective posttest counseling and linkage to care for those found to be HIV positive.