amfAR, The Foundation for AIDS Research

Take The Test, Take Control: The CDC’s Dr. Jonathan Mermin Talks HIV Testing

According to the U.S. Centers for Disease Control and Prevention (CDC), of the 1.1 million Americans with HIV, 18 percent—or about 200,000 people—don't know it. Among HIV-positive people aged 13–24, only 41 percent have been diagnosed. To mark the 18th annual National HIV Testing Day on June 27, amfAR talked to Dr. Jonathan Mermin, current director of the CDC's Division of HIV/AIDS Prevention, about the importance of routine HIV testing and how everything from over-the-counter testing to the implementation of the Affordable Care Act could impact HIV testing and the national epidemic. Dr. Mermin will take over as director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at the end of July. For more information about events or testing locations and resources, visit the National HIV Testing Day website, www.hivtest.org or www.gytnow.org. And get tested today.

MerminDr. Jonathan Mermin, director of the CDC’s Division of HIV/AIDS Prevention. amfAR: In 2006, the CDC issued new guidelines that recommended that HIV become a routine part of medical care for all Americans aged 13 to 64, but the majority of Americans still have never had an HIV test. What effect do you think making testing more routine would be on HIV rates and on the health of HIV-positive people in this country?

Dr. Jonathan Mermin: In the United States we have tremendous disparities related to HIV. African Americans are eight times more likely and Latinos are three times more likely to have HIV than white Americans. Gay and bisexual men are over 40 times more likely to have HIV than other men. And poverty, unemployment, and living in urban settings all can lead to increased risk for HIV infection. Yet the ability to get tested doesn't always go along with risk, so being able to provide routine screening for people when they go to the doctor or the emergency department will help everyone get tested and potentially reduce the HIV-related health inequities we see in the nation.

HIV testing is at the nexus of prevention and treatment. It benefits both. Helping people get tested, and also getting them into care and helping them stay engaged in care are critical steps. They will improve the health and survival of HIV-positive people and decrease transmission rates, and this will help us reduce national HIV incidence. Taking antiretroviral therapy and having a low viral load reduces the chance a person will transmit HIV, and being diagnosed and receiving regular care reduces risk behavior by people with HIV, even without antiretroviral therapy.

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amfAR: Could you describe the CDC's current guidelines and how adoption of these recommendations has progressed over the last seven years?

Mermin: In 2006, several studies had indicated that persons with HIV had had numerous healthcare visits but were not tested until too late to benefit fully from effective therapy. Screening all patients rather than focusing on those perceived to be at high risk helps identify people with HIV earlier. The CDC guidelines recommend an opt-out approach that makes testing routine, similar to cholesterol screening or a blood pressure check. The approach involves notifying patients that an HIV test will be performed unless he or she elects to decline testing.

Currently, 48 states plus DC have HIV testing regulations that are consistent with the CDC's 2006 recommendations—nearly twice as many as when the recommendations were first released.

In addition, more Americans are being tested for HIV than ever before. In 2000, only 37 percent of adults had ever been tested for HIV, and in 2010, 45 percent had been tested.

However, implementation in individual healthcare centers has not been as high as we would like. Assessments of emergency department visits in 2009 in hospitals where the prevalence of undiagnosed HIV infection is greater than 0.1 percent indicate that less than two percent of patients had actually received an HIV test. But hospitals that have implemented routine screening have had a great deal of success. Generally there is a doubling and tripling of the number of HIV diagnoses.

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amfAR: The Affordable Care Act takes effect in six months, and in April the U.S. Preventive Services Task Force (USPSTF) finalized its recommendation that testing become routine. What impact do you think this might have on HIV testing?

Mermin: I think this is going to increase HIV testing for a variety of reasons. The changes to the healthcare system over the next couple of years should increase the number of people who get access to testing. Also, pre-existing conditions cannot be used as a reason not to provide insurance, so because of increased access to health insurance and Medicaid expansion, more people with HIV should be accessing regular care and benefiting from preventive services. This could also potentially reduce stigma, which is a major barrier to HIV testing. Stigma is often hard to measure, but can be a substantial factor in affecting people's comfort about and access to services.

The U.S. Preventive Task Force had initially issued recommendations that were not consistent with recommending opt-out testing, but there is now consensus from the U.S. government. The task force's recommendation of routine HIV testing means it must be covered by most private and public health insurance plans without cost. So this not only sends a message to healthcare providers that it is important, and something that they should be considering, but it will also limit the extent to which lack of coverage has been a barrier to HIV testing.

amfAR: Has the wider availability of rapid oral HIV tests had an effect on rates of testing? How about the FDA approval of the sale of rapid tests over the counter last summer?

Mermin: Rapid HIV tests made getting a test easier, primarily outside the healthcare system. There are many community-based organizations that reach people at high risk for HIV infection in sometimes unusual settings, like bath houses or bars or on the street or other places where an easy-to-administer rapid test makes a great deal of sense. The recent approval of the over the counter HIV test presents an exciting opportunity. They could potentially reach people who might not get to the healthcare center regularly or get tested when they do visit their doctor. They can also potentially be used by people who should be tested more frequently than they normally visit the doctor.

amfAR: Is the CDC doing anything for National HIV Testing Day?

Mermin: We just launched the "What's your reason?/Cuál es tu razón?" campaign. It is our first national effort to encourage HIV testing in Latino men who have sex with men. It launched on June 6th in Los Angeles and will launch on June 26th in Miami. I would like to add one more thing, at CDC, every day is HIV Testing Day.