Editorial

from Medscape General Medicine™
Posted 05/15/2003

Sara M. Mariani, MD, PhD

Public attention has been captured in the past few weeks by a number of events that are generating anxiety and deep concern among many people, such as the events taking place in the Middle East and the more recent spread of severe acute respiratory syndrome (SARS) across the world. Yet, there are still very pressing old issues that demand our attention and care within our own communities, such as prevention and appropriate diagnosis of HIV infections, as well as prenatal diagnosis of HIV-positive mothers to implement prophylaxis.

Far too many young and not-so-young people and neonates are still becoming newly infected or are unaware of their HIV status, even in the United States. According to the latest estimates from the Centers for Disease Control and Prevention (CDC), of about 850,000 to 900,000 people living with HIV in the United States, approximately 200,000 (25%) do not know they are infected with HIV and obviously are, thus, not getting appropriate treatment.

In addition, the number of people at risk who delay testing or do not receive results after they are tested is still far too large. According to unpublished data from the CDC, almost one third of individuals with HIV-positive tests did not return to the clinics to learn of their results and approximately 40% of subjects in a group surveyed in 2002 underwent HIV testing only when they came to observe illness.

The availability of effective antiviral agents has significantly improved the prognostic possibilities for many people with AIDS, although perhaps concomitantly providing for some an unrealistic sense of safety or an "alibi" not to be concerned. Of course, prevention, whenever possible, or early treatment if infected are the best ways to lead a healthy life with an opportunity for happiness.

To facilitate HIV testing among larger populations, the CDC has recently changed the procedures to be followed. As illustrated in a recent Morbidity and Mortality Weekly Report,^[1] while launching a new initiative called "Advancing HIV Prevention: New Strategies for a Changing Epidemic," the CDC advocates the adoption of new, quicker screening tests that require only one visit while dropping the requirement of a pretesting counseling session. Streamlining testing for HIV should help more people feel that this is an easily accessible procedure that can quickly help them learn of their HIV status. Omission of the pretesting counseling may also prompt more physicians and other healthcare professionals without extensive experience in counseling to contribute to more widespread HIV-testing among individuals at risk.

This is made possible by a new diagnostic test, approved by the US Food and Drug Administration (FDA) in the past few months, that can provide an answer in 20 minutes. Another test in the pipeline, not yet approved by the FDA, might be even quicker, yielding results in as little as 3 minutes. The advantages these tests provide lay also in the fact that the reagents can be easily stored at room temperature, and they do not require special equipment, so the tests can be easily performed outside clinical settings. As in the past, positive results still need to be confirmed by Western blot or immunofluorescence assays and followed up with appropriate counseling and treatment, when necessary.

A call for routine HIV testing is envisioned, in this initiative, for all pregnant women, or when this fails, routine screening of the infants. The availability of quick testing during labor or at delivery will allow identification of neonates being born from HIV-positive mothers, who require immediate treatment. Awareness in the vast majority of HIV carriers of their status, with appropriate prevention counseling, should also help in modifying personal high-risk behaviors and thus limit involuntary spreading of HIV. More frequent and quicker testing is expected also to facilitate partner(s) notification and testing, thus further reducing the risk of involuntary spread.

The concern that HIV infection rates might now be rising after the decline in morbidity and mortality from AIDS seen in the '90s has grown considerably. This concern needs to be addressed with primary prevention and early diagnosis strategies across all populations at risk, especially those who may not have easy access to healthcare services. Even in these complicated and troubled times, all healthcare providers and prevention programs in the field should aggressively work to ensure control of this infection and appropriate care for all people involved.