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
And get tested today.
Dr. 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
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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
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.
¿Estás Seguro De Que Eres Negativo? [Mitos] y [Verdades] Sobre la Pruebadel VIH
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?
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.