AIDS At 25: Everyone To Be Tested

The CDC will recommend at least one HIV test for everyone aged 13 to 64 who visits a doctor.

The radical change to HIV testing guidelines will be released in June or July, says Kevin Fenton, MD, PhD, the new director of the CDC's National Center for HIV, STD, and TB Prevention. Routine HIV tests in doctors' offices and clinics will no longer require the pretest counseling now a part of all HIV testing.

Fenton, joined by former CDC AIDS chief James Curran, MD, MPH, now dean of Emory University's Rollins School of Public Health, spoke today at a news conference marking the 25th anniversary of the AIDS pandemic.

"Most HIV is transmitted by the 25% of infected people who do not even realize they are infected," Fenton said. "We need to dramatically expand access to HIV testing by making it a routine aspect of clinical care."

Pretest Guidelines

Fenton said current guidelines make it impossible for busy doctors and nurses to offer routine HIV tests. That, he says, is because the guidelines call for detailed pretest counseling.

Because HIV testing has never been routine, people who ask for the tests usually have a reason to suspect they may have been exposed to the AIDS virus. The counseling includes safe-sex information. It warns people who test negative to improve their safe-sex behavior. And it helps prepare people who test positive for what will be a lifetime of medical care.

Routine testing in a medical setting, Fenton says, is a horse of a different color.

"What we want to do is to address barriers to testing in clinical sites," Fenton says. "We know that a barrier is the significant time it takes for pretest counseling. … HIV testing outside clinical settings will still bear the requirement for pretest counseling."

Timothy Mastro, acting director of the CDC's Global AIDS Program, says the idea is to make more people -- a lot more people -- aware of their HIV status.

"These new guidelines … recommend [changing] the nature of HIV testing so that it's not based on the risk to an individual or the community in which an individual resides, but routinizes testing of all people between the ages of 13 and 64," Mastro said at the news conference. "People with ongoing risk behaviors should be tested more frequently, but we think everyone should be tested at least once in the 13- to 64-year-old age group."

Testing is part of what disease trackers call surveillance -- the public health equivalent of knowing your enemy. Curran calls it the most important tool in fighting AIDS.

"Surveillance was the most important thing early in the epidemic," Curran said. "It continues to be the most important thing in designing and targeting prevention efforts to those most at risk -- and evaluating the extent to which those efforts are effective."

U.S. AIDS at 25

The CDC news conference focused on AIDS in America. But Curran stressed that HIV is a continuing worldwide disaster on an unprecedented scale. We forget this at our peril, he says.

"It is difficult to reflect after 25 years, back to June of 1981, to understand how something that began so quietly can be the fourth leading cause of death in the world," Curran said. "[AIDS is] something that is continuing to grow, with 2 million more people that are dying each year. It is something that seems to know no bounds in its stretch around the world -- causing 40 million human incubators carrying other infectious diseases. Something we thought was a small problem back then."

It's been 25 years of unprecedented scientific advances -- and 25 years of unprecedented suffering.

"I'm amazed by the scientific progress, but even more amazed by the insidious, inexorable progress of the virus around the world," Curran said.

Living With AIDS

Five hundred thousand Americans are among the 25 million dead from AIDS. A million more Americans now carry the virus -- and nearly 16,000 died in 2004. If you think it's easy to live with the AIDS virus, if you think AIDS drugs are a cure, think again.

"Living with HIV is not easy," Fenton said. "The drugs can cause serious side effects and sometimes don't work for the long term. We need to reduce the number of people who become infected in the first place. Twenty-five years into the epidemic, prevention is the only cure we have."

There are still an estimated 40,000 new HIV infections every year in the U.S. Even though AIDS drugs can prevent mother-to-child transmission, 300 U.S. babies are born with HIV infection every year.

New Face Of AIDS

The epidemic is changing. The face of AIDS is becoming increasingly that of a black American man or woman.

"New infections hit African-American men and women hardest," Fenton said. "They account for half of all new HIV diagnoses and more than a third of AIDS deaths. African-American men who have sex with men are especially hard hit. Recent data show significant declines in AIDS diagnoses in nearly every group of African-Americans except in black men who have sex with men. A recent study in five U.S. cities found half of black men who have sex with men are infected with HIV."

White or black, men who have sex with men still make up half of all Americans with HIV. But infections among women are on the rise. In 2004, 26% of all new HIV infections -- more than one in four -- were in women.

Preventing AIDS

The only way to stop AIDS in America is prevention. AIDS is, after all, 100% preventable. It's popular to think that we can't do better than we're already doing. Curran said the lessons of 25 years argue otherwise.

He notes that nobody thought AIDS drugs could be as effective as they are. Skeptics laughed at the idea that mother-to-child HIV transmission could be prevented. The skeptics who scoff at effective HIV prevention are just as wrong, Curran said.

"Prevention works if its hands are not tied by local, national, and international political considerations," Curran said. "We know that peer-based and population-based efforts work if there are appropriate levels of resources. Prevention is difficult, though, because of stigma and denial and because of the poverty most people with HIV are mired in. Stigma remains the greatest barrier to prevention. It is the reason many people refuse to be tested for HIV -- that as well as poverty."

SOURCES:CDC news conference with James Curran, MD, MPH, dean, Rollins School of Public Health, Emory University, Atlanta. Kevin Fenton, MD, PhD, director, National Center for HIV, STD, and TB Prevention, CDC, Atlanta. Timothy Mastro, MD, acting director, Global AIDS Program, CDC, Atlanta.

By Daniel J. DeNoon
Reviewed by Louise Chang, M.D.
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