Dr. Thomas Frieden, the city health commissioner, is seeking far more than just eliminating signed consent forms for HIV testing. He is proposing the wholesale elimination of informed consent.
In the latest issue of the City DOH newsletter, City Health Information, examples are given of how to obtain consent. One example for a patient with diabetes, hypertension, and hypercholerolemia goes as follows: “Ms. A.—Today, I am going to do the following blood tests: check your fast sugar, and cholesterol, your kidney function, and do an HIV test. Do you have any questions?” Presumably under this scenario, if the patient says no, that constitutes consent to be tested.
But that isn’t consent, and it is certainly not informed consent.
As Frieden acknowledges, last year, the state department of health significantly modified the regulations for HIV counseling and testing, making a brief conversation and a patient’s signature all that is required before administering the test. This change has eliminated any legitimate barrier to dramatically expanded testing, while still recognizing the role of pre-test counseling and the fact that stigma against people living with HIV and AIDS persists.
What Frieden wants to eliminate is even the most basic conversation about the causes of transmission, likelihood of infection, and even fundamental prevention education, all in the name of routinizing HIV testing.
What he doesn’t say is that the real barrier to routinized testing is that most doctors don’t like having conversations with their patients about sex or about drug and alcohol use. But these conversations are an essential part of good health care, particularly in a city where 1.3 percent of the population is known to be infected with HIV.
Housing Works strongly supports routine universal voluntary testing in health care settings and other locales as well. HIV testing is important and it is how transmission of the virus can be prevented. There are many effective strategies for expanding HIV testing and improving access to care that New York Health Commissioner Thomas Frieden and the City of New York have the power and the responsibility to carry out; yet these options remain inexplicably unexplored. These include offering voluntary HIV tests to everyone entering the city’s homeless shelter and corrections systems, and extending the city’s AIDS services to include low-income people who are HIV-positive but asymptomatic.
The commissioner would do better to implement these improvements in services before demanding dramatic change in a state law that has provided vital protection to people living with HIV and AIDS for nearly two decades.
As to use of medical records, the issue is whether or not it is an appropriate role for the department of health to intervene in a private doctor-patient relationship when a patient is already in care for his or her HIV infection. The very fact that lab work has been done establishes that such a relationship exists. The hypothetical about the patient who has changed doctors is nothing more than a straw man. The first thing a new doctor would do is order lab work, which that professional would have in a matter of days.
People with HIV would be better served if Frieden invested the health department’s resources into more extensive education programs for both doctors and patients, particularly in high-incidence communities that are medically underserved.
Charles King is the president of Housing Works, a community-based AIDS service organization that provides, housing, health care, advocacy and other services for homeless people living with HIV and AIDS.