Getting serious about cholera.

649 The move to make testing more routinely available, or even to require that physicians offer it to patients, has encountered little opposition. But there is resistance to the elimination of pretest counseling and specific written consent, as well as to the adoption of an opt-out standard. Although Frieden rejects mandatory HIV testing, many fear that without a requirement for written consent, testing would in effect become compulsory. “This is not informed consent, and it is not even consent,” said one activist. It is rather an attempt “to ram HIV testing down people’s throats without their permission.” According to advocates of change, the transformation of HIV disease into a complex chronic condition requiring long-term, ongoing clinical management means that the limits imposed when medicine had little to offer have outlived their justification. Proponents argue that prevailing requirements impede wide-scale testing because they are burdensome and time-consuming. Furthermore, they relieve physicians of an obligation to offer testing. Less often acknowledged is the fact that an opt-out approach shifts the burden from those who would choose to undergo the test to those who would refuse. Making it more difficult to say no may be justified by public health considerations, particularly by concern about preventable opportunistic infections in persons who are unaware of their HIV infection and about transmission to their sexual or needle-sharing partners. As state and local health policymakers consider the new CDC recommendations, it will be crucial that the assumptions — both spoken and unspoken — informing the new testing paradigm be the subject of open, ethically informed, and evidence-based discussion.