Opt-Out and Eliminating Consent for HIV Testing

President Obama's new AIDS Strategy calls for a renewed effort to reduce new HIV infections by 25%, increasing the number of people who know their status from 79% to 90%. Crucial to the success of this benchmark is to test more people for HIV. This is consistent with the Center for Disease Control's recent recommendations (in 2006) to encourage HIV testing to become a routine part of medical care. However, one of the more controversial aspects of this push is the distinction between 'opt -in' vs 'opt-out HIV testing. Opt-in testing generally refers to an opportunity for the patient to be asked, by a provider, if s/he would like to be tested for HIV. Opt-out testing means that a patient will be given an HIV test unless s/he chooses not to have one. The CDC has recommended opt-out testing as well as the elimination of written consent (a medical consent form that authorizes HIV testing).

As one might imagine, this is a pretty contentious topic, even among HIV advocates and medical providers. Supporters of opt -in testing and informed consent argue that people need to understand what they are being tested for and why. Moreover, they argue that eliminating written, or even verbal consent fails to address the reasons why so many people fail to be tested, at the expense of expediency. Ignorance, apathy, stigma and discrimination are still alive and well, they claim, and cannot be ignored. Opt-out testing proponents point to the growing members of people who do not know their HIV status, present for treatment in the latter stages of their disease and the glaring disparity of HIV among the poor and communities of color as evidence that the present system isn't working and that we need new strategies to address the soaring epidemic. They also minimize the impact of stigma and discrimination, due in part to the efforts to make HIV testing more routine.

Nowhere is this debate raging more than in New York City, which still hold the crown for the highest incidence of HIV of any US city. New York State requires written consent, but the current policy is being reexamined. So what is the right policy? One thing is clear: both sides seem to be focused on the same outcome, a reduction of HIV infection. Unfortunately, in an era of dwindling resources it is sad that there is not more consensus on this issue. What isn't clear if if the present policies around informed consent aren't working. There is evidence that many medical providers are not offering HIV testing to their patients, due in part to their discomfort with the subject. Moreover, there is evidence, some of which comes from New York itself that HIV testing is rising under the current rules.

I am concerned that if people are not given an opportunity for consent for HIV testing and to have the conversation that would likely take place with that medical provider, that much of the ignorance and misconceptions about HIV will remain. Moreover, if provider feel a conversation about HIV testing is uncomfortable, then how will they feel about giving someone a positive result? We clearly have a long way to go before our society sees HIV/AIDS as just a medical condition. Before eliminating informed consent, I feel that more training for medical providers, more and robust social marketing to reduce HIV stigma and a renewed emphasis to ensure that HIV testing is being offered in routine medical settings are more effective measures to increase HIV testing.