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GMHC Statement on Proposals
to
Expand HIV Testing and Care
As New York City, and the entire world, approaches the 25th anniversary
of the beginning of the HIV/AIDS epidemic, Gay Men's Health Crisis
joins others in the community in focusing on what must be done
to stop the spread of AIDS and HIV infection and to move us towards
a city and a world without AIDS.
Here in New York City, we face many challenges including racial
and ethnic disparities in the number of AIDS-related deaths, new
cases of HIV infection and disproportionately high rates of HIV
incidence and prevalence among populations such as black and Latina
women, gay and bisexual men of color and young gay men of all races.
Given these realities, we all must do more. GMHC strongly believes
that everyone has the right to accessible and voluntary HIV counseling
and testing, HIV prevention education and services, and quality
care and treatment. GMHC wholeheartedly supports the goals of reducing
the number of people who do not know their HIV status, increasing
the early detection of HIV infection, and assuring that all New
Yorkers living with HIV promptly receive the best medical care
available to them.
Voluntary HIV counseling and testing are essential components
of the strategies needed to achieve these goals. Various approaches
to increasing the number of people who are tested need to be explored,
including the routine offering of HIV counseling and testing in
health care settings. GMHC supports new approaches to HIV counseling
and testing. However, we believe strongly that counseling and testing
must be voluntary, and include meaningful written informed consent,
with information on what an HIV test means, along with linkage
to care and prevention for both those who test positive and negative.
Increasing the numbers of people tested is not enough.
Over the past year, New York City's Commissioner of Health and
Mental Hygiene, Dr. Thomas Frieden, has proposed several approaches
to the same goals widely shared by GMHC and others in the community.
These proposals include significant modifications to New York State
Public Health law 27F to streamline pre-test counseling and substitute
documented oral consent for written consent when conducting an
HIV test. We commend the Commissioner on promoting increased dialogue
on HIV/AIDS issues, particularly focused on stopping HIV.
Nonetheless, we have a number of concerns with the proposals as
stated and with the vagueness of some of them. GMHC is particularly
concerned over the proposed plan to eliminate the requirement of
written informed consent to HIV testing.
GMHC's recommendations to reach the stated goals are as follows:
Restructuring HIV Testing and Counseling Procedures
GMHC supports efforts to increase access to voluntary HIV counseling
and testing and to remove any barriers to getting more people
tested. These include making HIV testing and counseling a routinely
offered component of medical care, and streamlining testing and
counseling procedures. This process has already begun with the
increasing availability of rapid HIV tests and changes in HIV
testing and counseling procedures implemented last year by the
New York State Department of Health.
However, GMHC opposes changing the law to remove the requirement
for written informed consent. We are convinced that written consent
should continue to be required to ensure that HIV testing remains
voluntary in practice and not just in theory, that patients do
not simply acquiesce to being tested, are not in any way made to
feel coerced and that they fully comprehend the array of ramifications
associated with the testing results. In addition, it would appear
from a legal standpoint that providers would enjoy greater protection
from possible legal challenges with signed written consent forms
than from oral consent documentation.
In addition, there needs to be procedures instituted to assure
that those with positive test results are referred and linked to
appropriate medical care at the point of diagnosis. Upon receiving
their results, all individuals should have access to HIV prevention
education and services, including prevention counseling as needed,
to facilitate behavior changes that will prevent further transmission
and enable those who test negative to remain HIV negative.
Provider Training and Linkage to Care
As a practical matter, physicians do not routinely engage in conversations
with patients about their sexual activities and behavior. GMHC
recommends that medical providers be given sufficient training
with regard to issues of sexuality and HIV/AIDS to have this
discussion with their patients and educate them around their
health and safety. We believe that enhancing the physician/patient
relationship around issues of sexuality will produce the results
we are all seeking — encouraging people to get tested and
know their status, and reducing HIV transmission. Furthermore,
promoting patient/doctor discourse increases client awareness,
compliance and future treatment adherence.
We urge the city to use its leverage as the administrator of the
largest municipal health system in the country to establish a training
program with New York's medical training facilities that will enhance
the provision of medical services to all individuals, particularly
those most at-risk of being infected, such as the Lesbian, Gay,
Bisexual Transgender community, people of color, and women.
We believe HIV counseling and testing, linkage to care and linkage
to HIV prevention are especially important in communities with
a high prevalence of HIV and believe that there are significant
gaps in these services that must be addressed.
Community Involvement
In line with the universal desire to remove any barriers to HIV
testing, GMHC is supportive of routinely offering HIV testing
in medical settings, but also recommends expanding HIV testing
and counseling offered by community based organizations, along
with the involvement of members of the community. This type of
grassroots effort has a demonstrated record of success in getting
people tested and referring them to appropriate medical care,
and should be continued. As an example, with the increased availability
of rapid testing, GMHC recently launched a mobile testing van
that has captured the attention of at-risk individuals who might
not otherwise have sought out testing.
Stigma
Testing for HIV is not the same as testing for cholesterol. Telling
one's family that you have HIV as opposed to cancer is likely,
even in 2006, to elicit a response that is less than supportive.
Being diagnosed as HIV-positive carries overtones of sexual transmission,
and is often linked to substance use and being gay, all of which
carry stigma.
Given the realities of our environments, it is imperative for
someone about to take an HIV test to understand the implications
of the test and its results. Maintaining counseling will not only
help individuals cope with the test results if positive, but also
help people who test negative stay negative.
Restructuring Patient Monitoring Procedures
All individuals entering the testing process should be assured
that they have access to the best quality medical care.
The Commissioner proposes changing Article 27F of the State's
Public Health Law to allow the New York City Department of Health
and Mental Hygiene to contact providers and their patients when
reportable laboratory test values indicate unaddressed problems
with their medical care.
Doctors and testing facilities currently report positive HIV tests
and AIDS diagnoses to the department. Additionally they report
HIV RNA tests that measure the amount HIV in the blood, CD4 cell
counts that reflect the health of the patient's immune system,
and resistance tests, which assess the susceptibility of the patient's
virus to HIV medications.
GMHC is concerned with the vagueness of the proposals and their
application to changes to Article 27F. We are also concerned that,
as presented, the proposals blur the distinction between legitimate
public health interventions and individual health care.
We are seriously concerned with the vague nature of these proposals,
most notably the lack of discussion regarding resources needed
to implement the level of monitoring recommended.
GMHC sees some potential for an important intervention if newly
infected people who are highly infectious are able to be identified
and linked to care. However, it seems there are already protocols
in place for identifying this population, and for providers to
respond. The public needs to see much more compelling data in order
to be assured that overhauling state law is necessary.
Provider performance is an area of major concern and we see nothing
in the current state law that prevents a public health agency from
reaching out to those providers in a non-patient specific way in
order to promote standard practices. We would strongly support
efforts to provide routine updates on treatment for providers and
believe that this is an appropriate role of a public health agency.
GMHC commends the Department of Health and Mental Hygiene and
Commissioner Frieden for opening a dialogue on these issues, and
hopes that in this spirit of partnership the Commissioner will
bring more people living with and affected by HIV/AIDS, providers,
community leaders and organizations together to craft a truly common
vision for the health of city and stopping the HIV/AIDS epidemic.
© 2006 Gay Men's Health Crisis
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