Data questions health department contention that written consent gets in the way
A study of 3,464 blood samples collected at city-run clinics and hospitals that showed that HIV testing is increasingly capturing New Yorkers who are recently infected with the virus may undercut the health department’s rationale for changing the state law that governs HIV testing, an effort aimed at identifying people living with the virus earlier in their infection.
“It weakens their argument about getting rid of written consent,” said Cynthia Knox, deputy executive director of the HIV Law Project, an AIDS group.
The samples were gathered between June 1, 2000 and December 31, 2004 and tested with the so-called detuned assay that is able to identify those HIV infections that occurred recently. In the study, a recent infection was defined as occurring less than six months before the blood sample was taken.
Among all groups, HIV diagnoses that were classified as “recent infections gradually and significantly increased from 14.6” percent of all new diagnoses in 2000 to 32.3 percent at the end of 2004.
Among gay and bisexual men, that number “rose significantly” from 21.4 percent to 43.1 percent and “other significant increases were observed among blacks, Hispanics, and persons age 25 and over,” according to the study abstract which was released at the 16th International AIDS Conference in Toronto.
No “significant change was observed among females” with the percentages going from 15.3 to 19.6. Among all males, recent infections went from 14.1 percent of all new diagnoses to 32.3 percent.
“[T]hese trends may be evidence of successful efforts for case finding and increasing awareness of HIV status in NYC, leading to more timely diagnosis of HIV and improved ascertainment of incidence by the surveillance system,” the study concluded.
These increases came at a time when providers were required to obtain written consent for HIV testing and give pre- and post-test counseling. In 2005, the pre-test counseling requirement was ended and providers can simply give a brochure to those getting tested.
Dr. Thomas R. Frieden, the city’s health commissioner, wants to change state law to replace the written consent requirement with documented verbal consent. Frieden has argued that the written consent requirement prevents providers from offering HIV tests.
“I think it could be an argument against changing the law,” wrote Jay Laudato, executive director of the Callen-Lorde Community Health Center, in an e-mail. “What the article is saying is we are finding more people sooner in their infection.”
Part of Frieden’s rationale is that roughly 25 percent of New Yorkers who are newly diagnosed with HIV get an AIDS diagnosis at roughly the same time. That progression typically takes eight to ten years. The study does not undercut that argument.
“[I]t doesn’t really refute Frieden’s claims that hard to reach groups are not being identified early and so they are unknowingly infecting others and also becoming more seriously ill because of a lack of treatment,” Laudato wrote.
Speaking by phone from Toronto, Dr. Lucia V. Torian, director of the city health department’s HIV epidemiology program, attributed the results to a number of influences including regular testing by people who are engaging in risky behavior.
“I think what you are seeing here are routine testers that are risked-based testers,” she said. “You are also seeing the effect of a city push to encourage routine testing and the effect of the rollout of rapid testing in 2004.”
The study may not represent the entire city.
“The sample is drawn from people testing at city sites only,” Torian said. “I think it would be very hard to draw any conclusion about that sample.”
The health department did not calculate the HIV incidence rate, or the percentage who are newly infected in a year, of the study samples. That rate is used to determine if new infections are increasing or decreasing in a population.
“We don’t, frustratingly enough, have incidence rates yet,” Torian said. “That’s our absolute intention and to able to follow them prospectively over time… When we have a year’s worth of testing, we’ll have a baseline of incidence rates and we can follow them over time.”