Systemic steroid treatment of paradoxical upgrading reaction in patients with lymph node tuberculosis.

Sir—We appreciate the comments by Sartin et al. [1] on our article [2] encouraging routine HIV testing. For HIV testing to become a routine part of medical care, procedural barriers, including signed informed consent and pretest counseling, need to be reexamined. The policy of obtaining signed informed consent prior to HIV testing was created to protect the privacy of patients at a time when therapy for HIV infection was minimal or nonexistent. Pretesting requirements have not changed in concordance with the development of HAART. Now, with widespread availability of potent antiretrovirals, pretest requirements need to be minimized to increase the number of individuals being offered HIV tests. As noted by Sartin et al. [1], there are already new federal policies in effect to protect patients’ private health information. Pretest counseling also needs to be simplified. As recommended recently by the Centers for Disease Control and Prevention [3], pretest counseling should not be a barrier to testing. Rather than providing information through lengthy counseling, which many healthcare providers might view as overly burdensome, information regarding HIV infection and treatment can be provided in a more succinct form and a more time-efficient manner. Routine HIV testing will not necessarily cause a significant increase in paperwork and testing-associated bureaucracy, if pretest requirements can be modified. HIV testing can be incorporated into other healthcare activities, such as annual examinations. It can also be performed routinely with other routine blood testing unless patients “opt out.” Pretest counseling can be replaced by the provision of information about HIV infection via an appropriate written pamphlet. Further counseling will be necessary only for patients who test positive or those who identify themselves as being at high risk. We advocate, in concert with Sartin et al. [1], a reevaluation of HIV testing policies and procedures in order to eliminate barriers and obstacles to routine HIV testing. The only way to reduce the number of individuals who are unaware of their HIV-infection status is to increase the number of HIV tests being offered. It is time our testing policies catch up with our ability to treat HIV infection.