Sunday, December 10, 2006

An Ounce of Prevention is Worth a Pound of Cure: Criticizing the CDC's new HIV policy from a Sociological/Historical Standpoint-Sandra Abensohn

In September 2006, the Centers for Disease Control and Prevention (CDC) publicized their Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Healthcare Settings which aims to incorporate HIV testing in routine annual health care for all citizens between 13 and 64 years of age. This new proposal would no longer require patients to sign an informed consent or undergo pre-test counseling prior to testing. Additionally, HIV testing will now be “opt out,” meaning that the test will automatically be performed unless the patient elects to decline testing (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm). Although the CDC’s proposed recommendations are a step in the right direction, they fail to reach crucial populations, address stigmas which may dissuade people from being tested, and identify the true root of the problem (prevention).

Under the universal HIV testing policy, patients will be tested annually by their physician or health care provider. Unfortunately, not all Americans have a primary care physician or receive health care on an annual basis. People without insurance are less likely to see a primary care physician, and therefore are less likely than insured people to be tested for HIV.

Additionally, there are higher rates of HIV/AIDS infections among certain racial and ethnic groups within the United States. Hispanics make up 20% of those diagnosed with HIV, and yet more than 30% of all Hispanics are uninsured. African Americans make up approximately one half of those newly diagnosed with HIV/AIDS, and 20% of African Americans don’t have insurance (http://kaisernetwork.org). These statistics indicate that African Americans have the highest rates of HIV; however, due to lack of health care coverage, many will not benefit from the CDC’s new HIV testing recommendations. This high risk group, which could potentially slip through the cracks of the health care policy, demonstrates that there may be HIV testing disparities between races and ethnicities under the CDC’s recommendations.

Another concern is that intravenous drug users and people who engage in unprotected sex may place less emphasis on their health and wellbeing than the average American. These people exhibit dangerous behaviors which put them at great risk for contracting HIV and other sexually/blood transmissible diseases. According to the optimistic bias theory, people who engage in health compromising behaviors tend to have the illusion that they are invincible. They believe that they are less likely than others to experience negative health impacts as a result of their risky behaviors. Furthermore, engaging in health compromising behaviors, while acknowledging that it may lead to HIV, is a threat to one’s intelligence. In order to maintain a false sense of integrity, an individual is likely to under assess his/her risk for contracting HIV (http://www.users.muohio.edu/shermarc/p324opt.shtml). Due to inability to assess the danger they are in, intravenous drug users and people who engage in unsafe sex are not likely to seek preventative health care since they are unwilling to see the importance of modifying their behaviors. The new HIV testing policy, which relies on an interaction between a patient and a doctor, does not reach these medical-care-avoidant populations.

Although the CDC’s new HIV testing policy intends to test everyone who is at risk, it fails to reach the most critical populations. There are many high risk individuals who are uninsured and therefore less likely to receive the primary care which would provide them with HIV testing. Additionally, people who are intravenous drug users or engage in risky sexual behaviors have already put their health in the back seat, and are less likely to seek preventative health care. Since there is no cure for HIV, the best way to prevent it is by avoiding the behaviors which perpetuate the problem. Unfortunately, the CDC’s new policy neither addresses behavior modification nor makes any attempt to reach these high risk groups.

In addition to excluding high risk individuals, the new HIV testing policy does not address the stigma associated with HIV/AIDS. Stigma encompasses prejudice, discrimination, discounting, and discrediting aimed towards people who are HIV positive and their friends and families. In a study conducted by the MMWR, approximately 20% of Americans believed that people who had contracted HIV deserved it (http://www.cdc.gov/mmwr). This study illustrates that a considerable proportion of society is fostering HIV stigma. Another study, conducted in seven cities across the United States, indicated that stigma was associated with a significant decrease in HIV testing (http://www.caps.ucsf.edu/). Due to the testing policy’s failure to address the societal impact surrounding HIV testing, certain individuals may choose to decline testing, thereby negating the CDC’s testing policy.

Scrambler’s Hidden Distress Model posits that the fear of social isolation and discrimination may encourage someone with a stigmatized condition, such as HIV/AIDS, to conceal it and appear as if he/she was a non-stigmatized member of the community. By attaining non-stigmatized status, the individual is able to prevent the otherwise inevitable social isolation and discrimination; however, his psychological wellbeing may suffer as a consequence (http://psychology.ucdavis.edu/). This implies that some people who suspect that they may be HIV positive could decline HIV testing in order to avoid potential stigmatization. Additionally, under the CDC’s new policy, there will no longer be counseling prior to receiving the HIV test. Pre-test counseling could have potentially eased the stigma surrounding HIV by educating society about HIV transmission, explaining the confidentiality of the test, and resolving stigmatizing fallacies. Unfortunately, the CDC’s new testing policy does not address the stigma concerning HIV, and may initially amplify stigma since it has eliminated pre-tests counseling.

Lastly, the CDC’s new HIV testing policy fails to focus on HIV prevention. Instead, the policy is only concerned with identifying and treating people who have already become infected with the virus. The CDC’s policy falls short in that it doesn’t help to prevent future cases of HIV and spends an exorbitant amount of time, money, and energy on current and future diagnoses. From a historical standpoint, testing and treatment alone were not enough to sufficiently reduce HIV transmission. Microsoft founder, Bill Gates, donated millions of dollars every year to provide medications to those who were infected with HIV/AIDS. He eventually came to the realization that he could make more of an impact on the fight against HIV/AIDS if he focused on prevention rather than identification and treatment. At the International AIDS Conference in August 2006, Gates was quoted as saying: "The harsh mathematics of this epidemic proves that prevention is essential to expanding treatment. Treatment without prevention is simply unsustainable.”(http://www.sfgate.com/cgi-in/article.cgi?file=/c/a/2006/08/14/MNGCIKHTRO1.DTL). Focusing on prevention is beneficial for society as well as the economy.

In conclusion, the Center for Disease Control and Prevention’s new policy fails to take into account prevention of HIV, and focuses solely on identification. Instead, the policy should focus on reaching out to high risk populations, making health care more accessible to minorities and addressing and eliminating social stigmas associated with HIV. The CDC’s new HIV testing policy was created with good intentions; however, it fails due to its inability to propose solutions while lingering on the problem.

“It is well known that ‘problem avoidance’ is an important part of problem solving. Instead of solving the problem you go upstream and alter the system so that the problem does not occur in the first place” – Edward de Bono

References

Barone, Mark; Becker, Julie. EngenderHealth’s Self-Instructional Module: STIs, HIV/AIDS, and Sexuality. 2003 (http://www.engenderhealth.org)

Berger E, Magnuson A: Optimistic Bias in Perceiving Physical and Mental Health Risks. Miami Ohio, 2002 (http://www.users.muohio.edu/shermarc/p324opt.shtml)

Bodenheimer TS, Grumback K: Understanding Health Policy: A Clinical Approach. New York, McGraw-Hill Companies, Inc. 2005

Branson BM, Handsfield HH: Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings 2006 (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm)

Ekstrand E. How does stigma affect HIV prevention and treatment? California, 2006 (http://www.caps.ucsf.edu)

Family Health International FHI: Behavior Change -- A Summary of Four Major Theories. 2002 (http://www.fhi.org)

Herek GM, Capitanio JP, Widaman KF. Stigma, Social Risk, and Health Policy: Public Attitudes toward HIV Surveillance Policies and the Social Construction of Illness 2003 (http://psychology.ucdavis.edu)

Morbidity and Mortality Weekly Report. CDC HIV-Related Knowledge and Stigma --- United States, 2000 Atlanta, GA (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4947a2.htm)

Russel S. Gates calls for emphasis on HIV prevention. San Francisco Chronicle, August 2006 (http://www.sfgate.com)

Satcher D. The Status of the HIV/AIDS Epidemic in the United States. New York, Henry J. Kaiser Family Foundation 2002 (http://kaisernetwork.org/)

3 Comments:

Blogger Michael Siegel said...

This is an outstanding critique. It really makes one wonder whether the incredible resources being devoted to "universal screening" might be better used on focused screening of high-risk populations and on disseminating more effective and more targeted prevention messages. You're astute in pointing out that some of the populations least likely to be screened by this policy are the precise groups most in need of screening. One also has to wonder whether this policy might increase socioeconomic disparities with respect to HIV/AIDS and contribute to a furthering of the stigmatization of those with HIV/AIDS. A very thoughtful and stimulating critque.

11:24 AM  
Anonymous Anonymous said...

Sandra, I liked your paper a lot. I think it is asking all of the right question. One assumption the CDC is making is that several uninsured folks will receive care in the emergency rooms and get tested there. So, they aren't assuming that people have primary care. This policy also will potentially further tax the health care system by adding several people (often uninsured) into the care system. Nice job. Rodney

5:39 PM  
Anonymous Anonymous said...

This is such an important issue, here in the states, and worldwide. Your paper makes the excellent point that the way to "cure" this disease is to openly invite discussion, and bring out all the facts that the general public doesn't know or is afraid to know. As the old saying goes, "Only the truth will set us free."

7:02 PM  

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