Routine HIV Testing Illegal in New York; NYC Officials Push for Change

Two articles about HIV testing in New York published this week:

New York Times: “Federal Policy Calling for More H.I.V. Testing Poses a Unique Challenge in New York”

New York Post: “City Hospitals Find 'Hidden' HIV Population

Federal Policy Calling for More HIV Testing Poses a Unique Challenge in New York


When it comes to H.I.V. and AIDS — the epidemic and its politics — New York has always looked different from the rest of the country. It has the nation’s highest rates of infection and illness, an unusual range of public and private services for those affected, and some of the biggest and best-organized advocacy groups.

Yet New York closely mirrors the national epidemic in some distressing ways, including this: About one of every four new H.I.V. diagnoses comes when the patient is found already to have AIDS. That means that in those cases, the infection went not only untreated, but undetected for a decade, on average.

Less than two weeks ago, the federal Centers for Disease Control and Prevention adopted a new, more aggressive policy on H.I.V. testing, saying that it should become a routine part of doctor visits. The agency and its supporters argue that finding more hidden infections would save lives, getting people into treatment earlier and persuading them to change their sexual behavior and reduce the spread of the virus.

That change, however, poses a political challenge in New York, where a state law passed in the 1980’s to protect the rights of people with H.I.V. and AIDS makes it impossible to carry out the new federal guidelines, which are voluntary.

While advocates agree that too few people are tested now, and that the C.D.C. recommendations will inform a continuing debate about the state law, people on all sides say there is no sign that the new federal policy would change things in New York.

The debate turns on ideas about civil liberties that are balanced a little differently in New York than in most of the country, and on widely differing theories about why millions of people who should be tested are not.

If this dispute lacks the fierce tone of past arguments about AIDS laws, experts say it remains more heated in New York than just about anywhere else. “We are still the epicenter of the epidemic,” said Dr. Marjorie Hill, interim executive director of Gay Men’s Health Crisis.

Since December, New York City’s health commissioner, Thomas R. Frieden, has made a serious push to change the state law, but he has made little headway in Albany. The Pataki administration has not taken sides, before or after the new federal guidelines. Advocacy groups that strenuously oppose Dr. Frieden, along with key lawmakers, say that nothing they have heard from him or the C.D.C. has altered their views — at least, not yet.

“What they’re recommending would require a significant change in New York law, and I am opposed to weakening the protections we have,” said Assemblyman Richard N. Gottfried, a Manhattan Democrat who is chairman of his house’s health committee.

The Senate’s health committee chairman, Kemp Hannon, a Republican from Nassau County, said he was open to arguments that the law should change, but cautiously so — in other words, he stands where he did all along. “I want to at least explore it and see where we can go,” he said.

New York law requires that a doctor or anyone else ordering an H.I.V. test must first have the patient read and sign an “informed consent” form, explaining the test and the patient’s rights, separate from the general consent forms often used to authorize a range of medical tests.

The law says that before the form is signed, the person ordering the test must provide “an explanation of the nature of AIDS and H.I.V.-related illness, information about discrimination problems that disclosure of the test result could cause and legal protections against such discrimination, and information about behavior known to pose risks for transmission and contraction of H.I.V. infection.”

If a patient tests positive, the person who delivers that news is required to provide “counseling or referrals for counseling” on the emotional effects of the diagnosis, the discrimination that could result, and the need to change sexual practices, among other areas.

A dozen or so states — experts disagree on the number — require specific, informed consent for H.I.V. testing; the others do not. Adding the required counseling before and after the test makes New York’s law one of the most stringent in the country.

The new C.D.C. guidelines tell doctors and other medical professionals that all adults and adolescents should be tested, and that people in high-risk groups should be tested once a year or more.

They say that health care providers should inform patients that the tests will be done, not ask their permission, though patients can still refuse, and that there should be no requirements for separate written consent or counseling.

Advocates of people with AIDS lobbied hard for the state law two decades ago, at a time when medical science offered little in the way of treatment. They argued that testing exposed people to severe discrimination, and that fear of testing without consent could actually dissuade people from seeing doctors. Such arguments held little sway in most states, but they carried the day in New York.

Public health officials who support the C.D.C. recommendations contend that things are different today, with medications keeping the virus in check for many years. They also say that the stigma of infection is less of a concern, a claim that advocates dispute.

A central question is why so many people still are not tested — even in New York City, where awareness of the disease is high and testing is widely available, as is treatment, even for those who cannot pay.

Both supporters and opponents of changing the state law say that too many doctors simply do not suggest testing to their patients.

Dr. Frieden and others argue that doctors cannot or will not take the time to take all the steps required by New York law to test their patients. “They have a huge number of things that they’re supposed to cover,” he said, while pressure from insurers to see more patients means that “they’re scrunching down to seven or eight minutes for a single clinical encounter.”

Those who oppose changing the law insist that informed consent is not a serious barrier, especially since the State Department of Health produced a simplified form last year.

The problem, they say, is that doctors are uncomfortable raising the subject — another sign of the stigma involved.

“I am an African-American woman in New York City,” part of a population at high risk, Dr. Hill said, and yet, “I have never had a provider ask me, would I like to take an H.I.V. test.”

Defenders of the current state law say that the way testing is handled is crucial.

“The C.D.C. recommendations might lead to more people being tested, but is that going to get them connected with a system of care?” said Julie Davids, executive director of the Community H.I.V./AIDS Mobilization Project. “That connection has to be made quickly and sensitively, or you’ll lose them, and they won’t get treatment.”

The other side says that sensitivity matters, but that testing matters more — after all, a person who is not tested is guaranteed not to be treated. Dr. Frieden said studies show that people who learn that they are H.I.V.-positive reduce behavior that could spread the virus.

“The more people who know their status, the fewer new infections you’re going to get,” he said. “For God’s sake, people are getting sick and dying, and they don’t have to. They’re spreading H.I.V. when they wouldn’t if they knew.”

New York Post

Tuesday, October 03, 2006

City Hospitals Find "Hidden" HIV Population


October 3, 2006 -- More than twice as many patients at the city's public hospitals and clinics were found to have the AIDS virus after the city dramatically increased HIV testing, officials said yesterday.

Health and Hospital Corp. facilities tested 92,000 patients in 2006 - a 63 percent rise - and that led to 1,514 patients identified as HIV positive - up from 720 in 2005.

Officials don't believe more people contracted the disease - only that more were identified due to the widespread testing.

The figures were released two weeks after the Centers for Disease Control told doctors to urge that all patients get tested. The Bloomberg administration has long urged New Yorkers to do so.

Health Commissioner Thomas Frieden is pushing to change state law to make testing easier. Current law requires a patient's written consent.

"We are aggressively offering testing to patients who come to us for routine physicals, heart disease, a sprained ankle," said HHC President Alan Aviles.

". . . We are lessening the stigma sometimes associated with HIV and helping connect many more HIV-positive individuals with early treatment."

HHC plans to test 150,000 patients over the next year.

Among those tested last year, 82 percent were women and 90 percent were minorities, mostly blacks and Latinos.

The testing took place in emergency rooms and outpatient clinics as well as through hospital admissions and discharges.

The New York Post

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