WEDNESDAY, JUNE 22, 2005

At the annual National HIV Prevention Conference sponsored by theCenters for Disease Control and Prevention (CDC) last week in Atlanta,it appeared to be business as usual, as prevention pros dissected thesexual habits of teens under abstinence oaths and gay men on theInternet. Down the hall, however, the federal agency itself was insteadtouting the success of an ambitious rollout of routine HIV testing, thecentral element of its 2-year-old prevention revolution nick-named“Prevention for Positives”—and AIDS service providers and communityadvocates were begging to differ. They called the program insufficientat best—it has fallen far short of its target of testing the 25% ofAmerica’s more than 1 million HIVers who don’t know their status—andpredicted disaster if, as proposed budgets indicate, treatment andcounseling don’t get a comparable boost.
    Routinetesting without follow-up treatment is a recipe for disaster, advocatesargue. “Once you’ve identified people who are positive, there is acertain obligation to provide services,” says Steven Sherman, NorthCarolina’s coordinator for its AIDS Drug Assistance Program (ADAP), thefederal program mandated to provide HIV drugs to low-income HIVers.ADAPs in North Carolina and nine other states are currently so brokethat newcomers languish on waiting lists or turn to drug-companyfreebies to save their health.
    “People are themost vulnerable right after they test positive,” says Jeff Graham, headof Atlanta’s own AIDS Survival Project. Testing programs that don’toffer referrals for treatment and care “can drive them away from thehealth-care system.” This costs taxpayers more in terms ofhospitalization, he notes, than catching them while they’re healthy.Some would argue, too, that it increases the likelihood of furtherinfections.
    The assumption behind the Preventionfor Positives HIV-testing blitzkrieg (the real name of the program is“Advancing HIV Prevention: New Strategies for a Changing Epidemic”) isthat people who know they are positive are more likely to practice safesex and protect their partners. While most studies support thispremise, research also suggests that members of certain groups—such as gay men inanonymous encounters and men on the down low who hide their risk-takingfrom wives and girlfriends—may buck the trend.
    Whenthe CDC first announced the new prevention initiative prior to itsannual confab two years ago, community concerns about adequate fundingfor increased treatment needs were trumped by a different crisis: theright-wing scrutiny of gay prevention that advocates viewed asharassment, as well as a mounting Bush push for abstinence-onlyeducation. The CDC got a pass. Now, two years later, the verdict is in:The feds will not provide a penny more for the Ryan White Care Act, theHIV services and treatment budget line, while cutting Medicaid to thetune of $10 billion. (The annual price tag for a three-drug cocktailis, at minimum, $16,000, far beyond most HIVers’ means.)
   So should the CDC be concerned that treatment shortages may turn peopleoff of testing? Despite prodding, reporters failed to get a directresponse on that last week from Dr. Ron Valdiserri, deputy director ofthe CDC’s National Center for HIV, STD & TB Prevention. Heacknowledged at the conference that it was “an important issue…tograpple with.” On the other hand, he said, “We are not aware of [anyresearch] showing a consistent disincentive to be tested.”   
   Few argue with the benefits of increased testing—and the 20-minute,saliva-based testing in the administration’s plan is quick andeffective. “The availability of rapid testing is incredibly important,”Graham says. Rapid tests tend to lead to more diagnoses than bloodtests—in one New Jersey study, 99% of people got their results,compared to the 65% who return after the standard five-to-seven-daywait.
    Still, the rollout of Prevention forPositives, in the form of rapid testing in clinics, hospitals, doctor’soffices and other once-virgin territory, has had the predictable effectof shortening the “counseling” conversations essential to both themental and physical health of the newly diagnosed and their capacity topractice safe sex. “[Counseling] can take time and the nature of thetest is rapid,” says John Peebles, who works with North Carolina’sdepartment of health. But with the CDC merely advising counselingrather than requiring it, these testing chats may increasingly beviewed as disposable, a luxury that cash-strapped medical professionalsforego.
    The burning question raised, but neveranswered, by this year’s CDC conference is, with both counseling andtreatment for people who test positive in dire jeopardy, is our federalPrevention for Positives initiative doomed to fail? The CDC’sValdiserri, no doubt, would say no. Only time—and the data—will tell.But one thing is certain: Next year’s CDC conference is unlikely to bebusiness as usual.