HIV Testing: My Doctors should have to ask….Shouldn’t they??

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HIV is Human Immunodeficiency Virus that has been identified as the virus that causes AIDS, a disease process that affects the human immune system by targeting and eventually destroying a persons T cells and putting them at risk for infections that would normally not be dangerous if their immune system was not damaged. Since the discovery of this disease much progress has been made in the diagnosis, treatment, and overall care of patient’s with the disease. Despite the aforementioned progress a cure is yet to be found and in turn a positive diagnosis means a life long need for treatment and care that patients should in general have the right to know and agree when, where, and by whom they are tested for the virus by. However, there are current laws in the United States, which allow physicians to test patient’s HIV status without an explicit consent for HIV blood work but with only a general consent for treatment.

Who is affected by this?

Currently this is an issue that affects the entire United States population that is seen in a physician’s office, clinic, or hospital across America. Each state has a variation of the current law/policies on their books but the state in particular that will be of concern in this blog is Ohio and in particular northeast Ohio region including Cleveland.

Whats the Issue?

This policy deals with the privacy and autonomy of patients in regard to their HIV status and diagnostic testing in the state of Ohio.

 

My Stance as a practicing physician.

I feel that as physicians we should not have the right to test patients for HIV without their consent when they are deemed competent to make decisions for themselves. I feel the only possible exception would be if the patient is unable to communicate and the knowledge would allow us to better treat their illness and potentially save their life.

 

Who is involved?

They issue recommendations for HIV testing in the Healthcare center along with providing resources for both patients and physicians taking care of patients with HIV. —-They note on their web site that they do not feel that anyone should have an HIV test performed on them without their permission.

 

Ankh THE FREE MEDICAL CLINIC OF GREATER CLEVELAND

They are noted to be one of the main centers in Northeast Ohio that provides testing  and care for HIV. —- Officially they are uncommitted, however they do obtain consent from patients before performing HIV testing.

They work in multiple capacities to help people with HIV navigate the reality of the disease, including but not limited to advocacy, testing, and counseling.—currently they appear to be uncommitted with no official stance on their website.
Community Hospital System located in Northeast Ohio, who is involved daily in testing for HIV in patient’s who have been admitted to the hospital or are being seen in the outpatient clinics.  HIV testing is performed without explicit consent by the patient’s on a regular basis. (the general consent obtained when patient originally was admitted to the hospital is used) —This is also there official stance per the legal department.
A non-profit Hospital System that spreads throughout Northeast Ohio that is involved with the daily testing and caring for HIV patient’s.   Hospital stance is that general consent is all that is needed in order to perform an HIV test on any patient. –which was documented in a memorandum that was circulated among physicians when the policy was changed.
Added Resource:
2011 Routine HIV Testing in Ohio Health Care Settings: Implementation Tool Kit
— This website summarizes the current laws and policies of Ohio while also giving a list of resources for both patients and physicians
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12 Responses to “HIV Testing: My Doctors should have to ask….Shouldn’t they??”

  1. kldrake Says:

    This is really an interesting topic, especially from a public health perspective. From a medical ethics standpoint, respecting patient autonomy is definitely violated by not asking patients for their consent for a test, especially one with potentially life changing and/or stigmatizing results. HIV tests are fundamentally different from say testing blood levels of potassium, and should be treated as such. But HIV also affects not just the patient, but others with whom the patient comes in contact.

    I am curious what you think of such policies from a broader, societal level perspective? When so many HIV positive people go undiagnosed, do we need to consider the risk we are putting others in society at by NOT testing everyone who sets foot in a hospital? What would be a better approach for increasing the number of HIV tests that are performed while still respecting patient autonomy and privacy?

    This is a challenging issue. Thanks for bringing it up!
    -Kelsey

    • kakuete Says:

      Thanks for your comments Kelsey. I agree with you it does create a very interesting dynamic because of the potential public health risk. However, in my opinion I in no way would discourage testing and screening, all I want advocate for is the need to allow the patient to make that decision and not be in the dark. I feel its important for a few reasons including the mental health of the patient involved, i.e what happens if the person who is tested without their consent turns out to be HIV positive is it possible that the news could be a tremendous trigger that could cause major depression, suicidal or homicidal ideations? Then also if they are not ready for the intense treatment are they more likely to stop getting treatment possibly creating more resistent strands of HIV?

  2. sbfphc Says:

    This issue arises in many countries where people have less understanding and more prejudices about HIV/AIDS. Testing at Antenatal Care (ANC) Clinics in many countries has not become routine in order to help prevent mother-to-child transmission. It took a while to evolve an opt-out system as in the early days testing was often done without a woman’s knowledge of the purpose of the test. Now there is better communication. In Rwanda for example, a woman is asked to bring her husband or partner to the first ANC visit so that they both can be tested. Efforts to maintain confidentiality are getting better, because again in the early days clients feared that staff would tell others their status. Overall this is an area of health ethics that appears to be still evolving.

    • kakuete Says:

      I agree so hopefully when asked more patients will have no problems with finding out their status, but giving them the opportunity to decide I feel will help them in the long run tremendously.

  3. lfenlason Says:

    As you noted, there is so much controversy surrounding this condition…. from so many sides.

    I hear your point about individual rights.

    With many barriers and stigma still present, its clear that these underlying issues need to be resolved in order to improve patients and community care in the long-term.

    But in the short-term… that is the question.

  4. kakuete Says:

    Yes the short term definitely posses a question that is hard to actually answer. I think if someone figures out that answer we would all be in their debt!

  5. tshegom Says:

    We had a similar situation in my country Botswana because our prevalence and mortality were so high at one point we needed to test everyone coming into the hospital in order to give services early. The idea was that testing everyone would essential benefit them and the society as a whole. Obviously with those measures people simply stopped coming to hospitals. What we have now is offering the services, every doctor and nurse has to offer testing and counseling and give the benefits of testing. It seems to be working and we also have a similar situation like Rwanda where men are encouraged to come with their partners for ANC appointments. It is a very fine line to cross though but we have found that better communication really helps

  6. polioerad Says:

    As a physician that practiced for many years in the developing world, let me say that I have been guilty of testing patients for HIV without their consent (this was many years ago!). However, it was widely practiced by all physicians that I knew. It wasn’t even taught in medical school then! I think the contributors were the fear of and stigma associated with HIV/AIDS and no one was taking any chances with this disease! In addition, I think medical practitioners in the developing world grossly underestimate the ability of their patients grasp information(that is a topic for another blog). All people need is clear and open communication and I am glad to note that doctor-patient communication in these parts of the world is slowly improving.

  7. blossom1000 Says:

    As a physician that practiced for many years in the developing world, let me say that I have been guilty of testing patients for HIV without their consent (this was many years ago!). However, it was widely practiced by all physicians that I knew. It wasn’t even taught in medical school then! I think the contributors were the fear of and stigma associated with HIV/AIDS and no one was taking any chances with this disease! In addition, I think medical practitioners in the developing world grossly underestimate the ability of their patients grasp information(that is a topic for another blog). All people need is clear and open communication and I am glad to note that doctor-patient communication in these parts of the world is slowly improving.

  8. olampkin Says:

    I have been in the military over 16 years and in the last 16 years I have been required to take an HIV test. I am not physician and I do not serve in a clinical capacity. The main reason the military test individuals is the ensure all members are getting the appropriate healthcare but it is also to protect our providers. I guess at this point I am immune to the rights of patients and I have never questioned their authority to test me. Now that you have brought up this subject I guess I would have a different perspective. In my early years my test results were not a concern because everything was in a paper file that I carry around with me to this day, but with the evolution of electronic medical records potentially anyone that is a healthcare provider may/can have access to my medical record and see my results of any test.

  9. alazarben Says:

    The issue of consent was discussed during one of the lectures given in HIV course by an MD from Hopkins hospital. I remember him mentioning that explicit consent was no longer required for HIV testing. He said most health care providers are not aware of this provision by the CDC. This reiterates Kelsey’s point above that we have to diagnose as many patients as possible for the societal good.
    Just a point though! I believe thorough pre-test and post-test HIV counseling are needed on top of the verbal/written consent. We have cases who were on a rampage of infecting others once they were declared HIV +ve. They really didn’t know (or care) the consequences to others or even themselves (who at times end up being infected with 2 or more subtypes of HIV virus). So what good does diagnosing so many patients do if people don’t change their behavior?
    The consensus currently is that HIV can be controlled by reducing the incidence either through use of an effective vaccine (which we’ve none) or/ and changing the behavior of people through effective health education campaigns. I overemphasize the latter. The HIV incidence in east Africa was remarkably reduced before ART (antiretroviral therapy) was even initiated. Uganda is a case in point. The president (Musevini if I am not mistaken) spearheaded massive health education campaigns in the country. What followed was a reduction in HIV incidence. In my opinion, more good is done to the society if people are empowered with knowledge of the consequences of HIV (or any sexually transmitted infection for that purpose).
    From a clinical point of view, we want to diagnose all those with HIV and start them on HAART. And eventually we want to make sure that they have undetectable viral load. From a public health point of view, we want to have low incidence of HIV globally. Be it the earlier or the later, patient autonomy remains one of the cornerstones of medical ethics.
    Thanks for raising and discussing this issue.

    • kakuete Says:

      Thanks for your comments! I just wanted to make one comment I do agree with you about the need for very good education however with the example of Uganda you really need take some of the fan fare with a grain of salt because a lot of the talk at that point was looking at the prevalence not the incidence which in some ways may have been due a lot to the rate at which people were dying not as much because of the success of the campaign because at that time they were promoting abstinence which as someone living in Kampala at the time doing HIV research it really did not appear to be working to the degree the media promoted it. Now with that said the education outside of the call for abstinence seemed to carry more weight and I believe there was a drop in incidence but just not as dramatic as the media made it seem.

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