June 20, 2005

The CDC Gets Testy

“Prevention for Positives” two years later: Slow rollout of rapid testing and a shortfall in treatment puts feds on defensive

WEDNESDAY, JUNE 22, 2005

At the annual National HIV Prevention Conference sponsored by the Centers for Disease Control and Prevention (CDC) last week in Atlanta, it appeared to be business as usual, as prevention pros dissected the sexual habits of teens under abstinence oaths and gay men on the Internet. Down the hall, however, the federal agency itself was instead touting the success of an ambitious rollout of routine HIV testing, the central element of its 2-year-old prevention revolution nick-named “Prevention for Positives”—and AIDS service providers and community advocates were begging to differ. They called the program insufficient at best—it has fallen far short of its target of testing the 25% of America’s more than 1 million HIVers who don’t know their status—and predicted disaster if, as proposed budgets indicate, treatment and counseling don’t get a comparable boost.
    Routine testing without follow-up treatment is a recipe for disaster, advocates argue. “Once you’ve identified people who are positive, there is a certain obligation to provide services,” says Steven Sherman, North Carolina’s coordinator for its AIDS Drug Assistance Program (ADAP), the federal program mandated to provide HIV drugs to low-income HIVers. ADAPs in North Carolina and nine other states are currently so broke that newcomers languish on waiting lists or turn to drug-company freebies to save their health.
    “People are the most vulnerable right after they test positive,” says Jeff Graham, head of Atlanta’s own AIDS Survival Project. Testing programs that don’t offer referrals for treatment and care “can drive them away from the health-care system.” This costs taxpayers more in terms of hospitalization, he notes, than catching them while they’re healthy. Some would argue, too, that it increases the likelihood of further infections.
    The assumption behind the Prevention for Positives HIV-testing blitzkrieg (the real name of the program is “Advancing HIV Prevention: New Strategies for a Changing Epidemic”) is that people who know they are positive are more likely to practice safe sex and protect their partners. While most studies support this premise, research also suggests that members of certain groups—such as gay men in anonymous encounters and men on the down low who hide their risk-taking from wives and girlfriends—may buck the trend.
    When the CDC first announced the new prevention initiative prior to its annual confab two years ago, community concerns about adequate funding for increased treatment needs were trumped by a different crisis: the right-wing scrutiny of gay prevention that advocates viewed as harassment, as well as a mounting Bush push for abstinence-only education. 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, the HIV services and treatment budget line, while cutting Medicaid to the tune of $10 billion. (The annual price tag for a three-drug cocktail is, at minimum, $16,000, far beyond most HIVers’ means.)
    So should the CDC be concerned that treatment shortages may turn people off of testing? Despite prodding, reporters failed to get a direct response on that last week from Dr. Ron Valdiserri, deputy director of the CDC’s National Center for HIV, STD & TB Prevention. He acknowledged at the conference that it was “an important issue…to grapple with.” On the other hand, he said, “We are not aware of [any research] 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 and effective. “The availability of rapid testing is incredibly important,” Graham says. Rapid tests tend to lead to more diagnoses than blood tests—in one New Jersey study, 99% of people got their results, compared to the 65% who return after the standard five-to-seven-day wait.
    Still, the rollout of Prevention for Positives, in the form of rapid testing in clinics, hospitals, doctor’s offices and other once-virgin territory, has had the predictable effect of shortening the “counseling” conversations essential to both the mental and physical health of the newly diagnosed and their capacity to practice safe sex. “[Counseling] can take time and the nature of the test is rapid,” says John Peebles, who works with North Carolina’s department of health. But with the CDC merely advising counseling rather than requiring it, these testing chats may increasingly be viewed as disposable, a luxury that cash-strapped medical professionals forego.
    The burning question raised, but never answered, by this year’s CDC conference is, with both counseling and treatment for people who test positive in dire jeopardy, is our federal Prevention for Positives initiative doomed to fail? The CDC’s Valdiserri, 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 be business as usual.