Wednesday, September 27, 2006

HIV and the ostrich

In a recent speech I had the opportunity to attend, Dr. Julie Gerberding, director of the CDC, illustrated a point about meeting the challenges of the future by bringing up the ostrich’s supposed behavior of sticking its head in the ground at the first sight of danger. She cited the relevant Wikipedia article, which reads:

. . .there have been no recorded observations of this behavior. A common counter-argument is that a species that displayed this behavior would not likely survive very long. . .burying their heads in sand will in fact suffocate the ostrich. When threatened, ostriches run away, but they can also seriously injure with kicks from their powerful legs.

I like the way that this logic applies to HIV testing and the new U.S. federal policy of recommending annual testing for at-risk teenagers and adults. Living with HIV, but refusing to be let aware of it and thereby foregoing the possibility of life sustaining treatment, like the ostrich burying its head in the sand, is a behavior incompatible with life. It also poses a substantial threat to public health. The current policy climate in most states of validating such behavior by requiring documented consent before testing simply no longer makes sense.

Consenting somebody for HIV testing is more nuanced than it sounds; you don’t just ask the patient whether or not you may test him or her. Obtaining informed consent means explaining the pros and cons of the proposed action, and for HIV, I have tended to say something like the following:

Sir, before testing you for HIV, as we are suggesting, I have to obtain your written permission. The reason for this is to make sure that nobody is tested without their consent or knowledge. The benefit of testing is that then we will actually know whether you have HIV, and if you do, you will be able to receive life saving treatment. The downside of testing is that if you do have HIV, it can be difficult news to take, and in the past there have been certain social stigma associated with the disease. Of course, I strongly recommend testing.

A speech like this immediately raises suspicions--if testing is such a good idea, why does it require documented consent? Clearly, HIV is not an easy diagnosis to receive, but neither are a host of other chronic diseases from herpes to leukemia. Can you imagine your physician asking you for documented informed consent before testing you for say, schizophrenia? I’m not suggesting that HIV testing should be mandatory; within reason physicians should obtain permission before testing for any disease, but let’s stop this charade of pretending that declining or delaying testing is a reasonable choice. In DC, where one out of twenty of our metro riders carry the virus, annual HIV testing for at-risk teenagers and adults makes particular sense.