Testing America’s common sense

Finally, some common sense in HIV testing policy in the US. Although you’d be hard pressed to know it from some of the coverage.

Until last Monday, America’s unfathomably illogical health service for the properly poor, Medicaid, refused to pay for HIV testing just as it refuses to pay for all sorts of other screening measures that could allow conditions to be treated early or in some cases prevented enitirely. Now, Medicaid has finally agreed to test its clients for HIV, if they fall into certain categories.

Here’s where the bad reporting comes in. This, for example, from The Goverment Monitor, which reports public sector news:

“The Centers for Medicare & Medicaid Services (CMS) today announced its final decision to cover Human Immunodeficiency Virus (HIV) infection screening for Medicare beneficiaries who are at increased risk for the infection, including women who are pregnant and Medicare beneficiaries of any age who voluntarily request the service.”

So, the two groups that they single out as being “at increased risk” for HIV are pregnant women, and people asking for a test. In fact, of people who have recently had unprotected sex in the United States, pregnant women are among the least likely to be infected with HIV.

The actual decision reads as follows:

CMS will cover both standard and U.S. Food and Drug Administration (FDA)-approved HIV rapid screening tests for:

1. Annual voluntary HIV screening of Medicare beneficiaries at increased risk for HIV infection per USPSTF guidelines:

* Men who have had sex with men after 1975;
* Men and women having unprotected sex with multiple [more than one] partners;
* Past or present injection drug users;
* Men and women who exchange sex for money or drugs, or have sex partners who do;
* Individuals whose past or present sex partners were HIV-infected, bisexual or injection drug users;
* Persons being treated for sexually transmitted diseases;
* Persons with a history of blood transfusion between 1978 and 1985;
* Persons who request an HIV test despite reporting no individual risk factors, since this group is likely to include individuals not willing to disclose high-risk behaviors; and

2. Voluntary HIV screening of pregnant Medicare beneficiaries when the diagnosis of pregnancy is known, during the third trimester, and at labor.

In other words, perfectly sensibly, pregnant women are NOT classified as at high risk for HIV infection, but are offered tests in any case since services to prevent transmission to their babies are available if need be. Now look at the list of those who ARE considered at higher risk. Again, it is mostly perfectly sensible. I’d prefer to see some sort of time stamp on number two — the overwhelming majority of Americans have had more than one partner in their lives, and most will probably have had unprotected sex with at least two of them. But that really doesn’t put them into a “high risk” category unless they are having sex with those multiple partners during overlapping time periods. Because HIV isn’t highly infectious for very long, you’d really like something more precise, such as “unprotected sex with multiple partners in any given three month period”. The biggest group at higher risk missing from the list is “men who have been incarcerated”. I agree that it is not the incarceration but the behaviours while incarcerated that put people at risk for HIV, and those behaviours are covered elsewhere on the list. But many people zone out what happens in jail — they are unlikely to report having sex with other men if it is something that they only do when they are banged up, for example. And yet we know many people in jail are infected with HIV, and we also know that many of them are having anal sex and shooting up drugs, and therefore likely to pass the virus on to other prisoners.

Another piece of good sense: the decision specifically authorises rapid tests. We know that people are far more likely to get their results and to be tied in to the support and care services they may need if they are offered on-the-spot tests, rather than having to come back or call in for results a week later. It would be nice if other countries (with generally better records on preventative medicine) followed this lead. Any Canadians reading this…?

This post was published on 11/12/09 in Science.

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  1. Comment by Chantal, 11/12/09, 09:26:

    Yes, a Canadian is reading this and agreeing completely. The one week waiting period is absolutely ridiculous. For one, the period OF waiting to get results is nerve-wrecking for risky or paranoid folk, and two, it encourages people to cease their risky behaviours and recieve help when they are potentially at their most contagious. Keep up the great work Elizabeth!

  2. Comment by Nico, 11/12/09, 11:12:

    As a gay man, I consistently refuse sex with pregnant women and/or *anyone* who has recently requested an HIV test as a sure-fire way to reduce my OWN risk of exposure LOL

    Rapid tests are available in at least some places in Canada (dunno about the whole country as health services differ on a provincial, even municipal basis).

    Ontario began rolling it out in 06/07:

  3. Comment by Samantha, 13/12/09, 04:45:

    It never ceases to amaze me the ridiculous beaucracy that Medicare imposes. My family has been battling the system for several years now for a completely different issue for my father’s condition and despite it’s charter to provide healthcare assistance, it never seems to meet the challenge of making sure that patients have what they need. When Medicare does finally recognize the obvious, instead of apologizing for their inaction, they annouce it as groundbreaking progress.

    I’m so glad that I found your site. Keep up the great work! I look forward to reading more!

  4. Comment by Dag Brück, 13/12/09, 07:16:

    Maybe The Governement Monitor just suffers from bad writing. It would make more sense if they wrote “at increased risk for the infection, *also* including women who are pregnant”.

  5. Comment by Manisha, 16/12/09, 05:01:

    I agree (I am too Canadian) and doing my Master’s thesis on exactly this!

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