To the Editor: We commend the call by Frieden et al. (Dec. 1issue)1 for a comprehensive public health approach to the epidemicof human immunodeficiency virus (HIV) infection. The authors'lack of evidence with regard to the relative impact of theircase-finding approach, however, raises questions about the scientificbasis for their conclusions. Given that there is considerablestigma against injection-drug users, men who have sex with men,and sex workers in many localities and institutions, it is importantto evaluate whether the case-finding techniques would increasestigmatization of those at risk and thereby weaken HIV-preventionefforts among stigmatized and fearful risk groups. Injection-drugusers in New York City began reducing their high-risk behaviorbefore AIDS was identified in 1981, and their effective effortsto minimize risk and to communicate methods of risk reductionstill continue.2,3,4 Organizing on the part of homosexual mensince the early days of the HIV epidemic has contributed tofar-reaching effects on policy, high-risk behavior, and communitynorms.5 Before the case-finding proposals of Frieden and colleaguesare implemented, research should determine whether they wouldweaken the prevention efforts of the populations at risk.
Samuel R. Friedman, Ph.D. National Development and Research Institutes New York, NY 10010 friedman{at}ndri.org
Susan G. Sherman, Ph.D., M.P.H. Johns Hopkins Bloomberg School of Public Health Baltimore, MD 21205
References
Frieden TR, Das-Douglas M, Kellerman SE, Henning KJ. Applying public health principles to the HIV epidemic. N Engl J Med 2005;353:2397-2402. [Free Full Text]
Friedman SR, Curtis R, Neaigus A, Jose B, Des Jarlais DC. Social networks, drug injectors' lives, and HIV/AIDS. New York: Kluwer Academic, 1999.
Friedman SR, Maslow C, Bolyard M, Sandoval M, Mateu-Gelabert P, Neaigus A. Urging others to be healthy: "intravention" by injection drug users as a community prevention goal. AIDS Educ Prev 2004;16:250-263. [Medline]
Des Jarlais DC, Perlis T, Arasteh K, et al. "Informed altruism" and "partner restriction" in the reduction of HIV infection in injecting drug users entering detoxification treatment in New York City, 1990-2001. J Acquir Immune Defic Syndr 2004;35:158-166. [Web of Science][Medline]
Kippax S, Race K. Sustaining safe practice: twenty years on. Soc Sci Med 2003;57:1-12. [Medline]
To the Editor: Hurray for Frieden et al. for clearly elucidatingthe need for applying public health principles to the HIV epidemic.As the authors point out, routine HIV testing as part of primarycare is indicated on the basis of clinical efficacy and cost-effectiveness.1,2,3Routine HIV testing is now recommended for all pregnant womenas part of their prenatal care, irrespective of perceived risk.4Written informed consent is a barrier to the implementationof these recommendations. Although written informed consentwas necessary in the past, improved knowledge of HIV and AIDSand current legal protections make such consent unnecessaryand burdensome in most settings. Although HIV testing shouldbe routine in a myriad of settings, it should not be mandatoryor coerced. Oral informed consent for HIV testing (as is standardfor testing for other sexually transmitted diseases) is appropriate.States should consider changing HIV-related regulations to doaway with mandatory written informed consent.
Timothy P. Flanigan, M.D. Curt Beckwith, M.D. Charles C.J. Carpenter, M.D. Brown Medical School Providence, RI 02906 tflanigan{at}lifespan.org
References
Sanders GD, Bayoumi AM, Sundaram V, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med 2005;352:570-585. [Free Full Text]
Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States -- an analysis of cost-effectiveness. N Engl J Med 2005;352:586-595. [Free Full Text]
Bozzette SA. Routine screening for HIV infection -- timely and cost-effective. N Engl J Med 2005;352:620-621. [Free Full Text]
Preventive Services Task Force. Screening for HIV: recommendation statement. Ann Intern Med 2005;143:32-37. [Free Full Text]
The authors reply: Increased detection of HIV infection benefitsinfected persons, their contacts, and the community. When HIVinfection is diagnosed before the onset of clinical illness,patients can decide when to start treatment and can avoid seriouscomplications. Patients who receive a diagnosis late in theirillness are much more likely to die within a year of diagnosis1;those who know they are infected reduce risky behavior by abouthalf.2
There is no evidence that a standard offer of voluntary HIVtesting as part of normal medical care will increase stigma.Indeed, persons may well encounter reduced discrimination ifvoluntary testing is offered universally in health care settings.
The stigma of an HIV diagnosis can be devastating, but the alternative— not getting care, spreading infection to others, continuingto encounter stigma, and dying prematurely of AIDS — iseven worse. A generation ago, cancer was stigmatized; it isnow markedly less so owing to increased identification of cases,improved treatment, and public education. We concur with Friedmanand Sherman that more research and action are needed to mitigatethe serious problem of HIV-related stigma.
We agree with Flanigan et al. that written consent for HIV testingnow represents a major and unnecessary barrier to helping patientsvoluntarily learn their HIV status. State laws requiring writtenconsent separate from the general consent for medical diagnosisand treatment should be changed.
Thomas R. Frieden, M.D., M.P.H. Scott E. Kellerman, M.D.,M.P.H. Moupali Das-Douglas, M.D. New York City Department of Health and Mental Hygiene New York, NY 10013 tfrieden{at}health.nyc.gov
References
Chadborn TR, Baster K, Delpech VC, et al. No time to wait: how many HIV-infected homosexual men are diagnosed late and consequently die? (England and Wales, 1993-2002). AIDS 2005;19:513-520. [Web of Science][Medline]
Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr 2005;39:446-453. [CrossRef][Web of Science][Medline]
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