Despite progress in testing Americans for HIV, lack of federal/private insurance impedes expansion

With projections that human immunodeficiency virus (HIV) infection rates are increasing in some populations, former Surgeon General Dr. C. Everett Koop -- who charted the nation's policies on HIV/AIDS following the first deaths from AIDS in 1981 -- today issued a stern warning to the public health community: HIV/AIDS continues to be a major epidemic and requires a national mobilization to identify and provide immediate care for many Americans with HIV who remain undiagnosed -- an estimated 200,000 people.  

Addressing the 2010 National Summit on HIV Diagnosis, Prevention and Access to Care, a biennial scientific conference convened by the Forum for Collaborative HIV Research, Dr. Koop called the public's lack of attention to HIV the "new front" in the nation's ongoing battle against this disease. Noting that one in every 300 Americans (1.1 million people) is infected with HIV and an additional 56,300 will become infected each year, Dr. Koop said the nation's growing complacency is as dangerous as the irrational fear in the first days of the AIDS epidemic.

"As someone who has been speaking out on HIV/AIDS for 30 years, I want to go public once more with the same message I delivered as Surgeon General – HIV is contagious and it can kill you," Dr. Koop said.  On a more positive note, Dr. Koop added that with HIV, knowledge is power: learning one's positive serostatus is the first step for newly diagnosed HIV patients to get linked to care and treated early in the disease process with the potential to have a nearly normal lifespan.

As the first major meeting to address the nation's prevention and detection efforts since the release of the National HIV/AIDS Strategy for the United States in July, this year's summit on November 17-19 will bring more than 350 HIV researchers, health care providers, policymakers and advocates together to create the pathway for accelerated adoption of routine HIV testing and for increasing patients' access to care – two strategies that will dramatically reduce HIV transmission and better support people living with HIV.

"If there was ever a time when we can change the course of HIV in this country, it is now," said Veronica Miller, Ph.D., Director of the Forum. "HIV testing is a crucial step in reducing HIV infections and getting newly infected people into care quickly when treatment will significantly improve their health outcomes. Elevating the need for routine HIV testing must become a new imperative to which we devote the resources of our communities and our nation."

Towards this end, the summit charted the progress to date in making HIV testing a routine part of preventive care and called for immediate action to eliminate the systemic barriers that are impeding further adoption: lack of federal reimbursement and private insurance coverage for HIV testing, state laws that require written consent, and complacency about HIV in gay and bisexual men that is leading to a significant increase in infection rates among this group.  These actions are essential if one of the major goals of the Obama Administration's new HIV/AIDS Strategy – increasing to 90 percent the number of HIV-positive Americans who know they are infected – will be met by the target date of 2015.

Confronting Two HIV Epidemics

Mobilizing the public health community around HIV prevention and early detection is especially warranted now that HIV infections among gay and bisexual men are on the rise and HIV has become a significant minority health problem. Presenting an update on the state of HIV/AIDS in the U.S., Dr. Kevin Fenton, Director of the Center for Disease Control and Prevention's (CDC) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), reported that:

• Men who have sex with men (MSM) represent 53 percent of all new infections and are being diagnosed at rates 44 times greater than other men and 40 times higher than in women
• African Americans now account for almost half of the U.S. population living with HIV (46 percent) and nearly half (45 percent) of the new infections each year
• Hispanics/Latinos have rates of new infections that more than double that of white men and nearly four times that of white women.

Late Testing Remains Major Challenge

Although routine testing is intended to stop HIV transmission and late entry to care, new data presented at the summit find that "late testers" -- those who develop AIDS within a year of diagnosis -- account for 40 percent of all new HIV diagnoses. Changing this trend is medically necessary because there is a 7 to 9 year lag after HIV infection, during which the infected person may unknowingly transmit HIV to others. Studies show that transmission rates are 3.5 times greater among undiagnosed patients compared to those who know their status. Moreover, delayed diagnosis with late entry into care is projected to result in 100,000 life years lost in the U.S. as well as significant costs to the health system for treating AIDS-related illnesses.

Illustrating the challenges for the public health community, summit leaders focused on data from examining health insurance records of late testers, which reveal many missed opportunities for diagnosing HIV earlier, when CD4 or T-cell counts are higher and antiretroviral treatment is more effective in prolonging survival. According to research studies, the average CD4 cell count in late testers in 190, which is alarming low. HIV infected people are considered to have "normal" CD4 counts if the number is above 500.

HIV Testing Accelerating But Impediments Continue to Hinder Progress

To further increase the number of Americans – particularly those at high risk – who get tested for HIV, CDC launched its HIV Testing Initiative in 2007. Originally focused on testing African Americans at high risk, the initiative has resulted in an additional 1.4 million Americans being tested for HIV since 2007, and in some 10,000 HIV-infected people being identified, most of which (75 percent) were linked to care.  These new statistics represent significant progress in implementing the 2006 recommendations from CDC that all Americans aged 13 to 64 years be tested for HIV when they receive care in hospital emergency rooms, clinics and other heath care settings.

Looking at the impact of expanded HIV testing at the community level, in Washington, DC, where at least 3 percent of residents are living with HIV or AIDS, the Department of Health reported new HIV diagnoses increased 17 percent after the city implemented an expanded HIV testing program in 2006. Accordingly, the average CD4 count among newly diagnosed cases also increased by 57 percent, meaning more people were diagnosed at an earlier stage when treatment is most beneficial.  Another innovative program in San Francisco increased by more than 4,000 tests when HIV screenings were combined with hepatitis A and B vaccinations and treatment for sexually transmitted diseases.

Despite these positive developments, however, summit leaders identified significant barriers that are impeding further success, especially current reimbursement policies that are linked to coverage recommendations from the U.S. Preventive Services Task Force (USPSTF) -- an independent panel of private sector experts that determines which preventive services should be incorporated into primary medical care. Although other routine screening tests, such as for cholesterol and triglyceride levels, rate an A or B grade and are recommended for coverage, USPSTF currently assigns HIV testing a C grade – defined as "offer or provide this service only if other considerations support the offering or providing the service in an individual patient." Accordingly, Medicare limits coverage for HIV testing, despite analyses that HIV screenings save $50,000 to $64,000 per quality adjusted life year.

In addition, Medicaid coverage -- which is the largest single source of care and coverage for people with HIV (an estimated 40 percent of HIV/AIDS patients receive services through Medicaid) -- is a state-by-state decision but because of the economic downturn, many states do not consider HIV testing a priority. Therefore, many people at risk for HIV are currently not eligible for coverage or, if eligible, face barriers to enrollment.

To change this situation, summit leaders called for more states to follow the examples of the District of Columbia and California, which enacted legislation requiring all health insurers to pay for HIV screenings. As with Medicare, most private insurers use the USPSTF recommendations when developing reimbursement policies and do not cover routine HIV testing.

"Although the nation is now 30 years into the HIV/AIDS epidemic, the health care system remains stuck in the past, despite increasingly effective treatment and promising new approaches for prevention," said John Bartlett, MD, Professor of Medicine, Chief, Johns Hopkins AIDS Service, Johns Hopkins University School of Medicine and a co-chair of the Summit. "There is so much that medicine can do to alleviate the impact of this devastating disease but we first have to expand access to a test that takes minutes and costs ten dollars. It is the only realistic way to reach more people with HIV early when treatment is most effective."

Another immediate priority for the HIV community is to remove the requirements in four states that still mandate signed consent forms: Massachusetts, Michigan, Nebraska and Pennsylvania. Since the CDC recommendations were published, the HIV community has been successful in removing laws and regulations in 16 states that previously required the separate written consent for HIV testing of non-pregnant adults.  Thus, today, 46 states and the District of Columbia have laws and regulations that are consistent with CDC's recommendations to use an "opt-out" approach under which HIV testing is part of the general medical consent.