Yesterday was National HIV Testing Day, a reminder for all of us to get tested for HIV. Among the one million Americans living with HIV, twenty percent do not know they are infected. This is despite Centers for Disease Control guidelines that recommend testing for all Americans between the ages of thirteen and sixty-four.
The consequences of not knowing one's HIV status can be devastating. I saw this firsthand a few months ago as a doctor on call at my local hospital.
Michelle was an Asian woman in her forties who had been hospitalized overnight. It was thought that she had a mild pneumonia. I took over her care the next morning and set off to check in on her before meeting my team for morning rounds.
Upon entering her room, I noticed that she was was thin-appearing and sleeping comfortably. I approached her gurney. Suddenly, the alarms went off. Her oxygen level was dropping dangerously low. This was unusual for a mild pneumonia. Could she have asthma or a clot in her lung instead? A list of alternative diagnoses ran through my head as I dialed up her oxygen.
Her nurse rushed into the room. "Someone from the lab is on the phone," she said. "Michelle's HIV test just came back positive."
She had PCP pneumonia, a rare fungal infection of the lungs that is seen when HIV cripples the immune system. If not recognized and treated promptly, it can be fatal.
Michelle's case reminded me that our country has not yet overcome AIDS. In fact, the rates of HIV infection in some American populations actually rival those in sub-Saharan Africa, the center of the global epidemic.
In Washington D.C., for example, one in thirty individuals is infected, a higher rate than in Ethiopia or Rwanda. New York City has the most infections in the country, with alarmingly high rates among specific populations: one in forty African Americans, one in eight injection drug users, and one in ten men who have sex with men. Increasingly, heterosexual women, not traditionally considered 'high risk,' are being diagnosed with HIV.
Despite such startling numbers, HIV is not part of our national consciousness as it was even a decade ago. In a 2004 debate, former Vice President Dick Cheney was criticized for not knowing that HIV is the largest killer of young African American women. Five years later, a Kaiser Family Foundation poll confirmed that fewer Americans thought that HIV was a serious problem domestically. Not infrequently, patients admit to me that they engage in risky sexual behavior without fear of contracting the virus. Many have not been tested.
Physicians bear responsibility for this trend as well. Despite universal screening guidelines, only seventeen percent of respondents in the Kaiser poll said that their doctor offered them an HIV test.
Thus, it is not surprising that a full one-third of Americans with HIV are diagnosed late in their disease. These are people that miss out on life-saving treatments and are likely to infect their partners without even knowing it.
Michelle was one of these people. By the time she was diagnosed, her immune system was irreversibly damaged. She was battling a life-threatening PCP infection. Fortunately, with intravenous antibiotics and steroids to reduce the swelling in her lungs, she eventually overcame the pneumonia. However, she had to endure a fifty-day long hospitalization in which she was nearly put on a breathing machine. All this could have been prevented had she been tested even once during the previous five years.
It is time that we all acknowledged the reality of HIV in our country. It is time for a renewed commitment to bring our domestic epidemic under control. We need a commitment from elected officials to increase funding for HIV programs, especially ones that expand testing. We need a commitment from doctors to offer testing to their patients. Most of all, we need a commitment from every American to understand their own risk of infection and get tested.
All of us have a role in overcoming HIV in America.
Identifying information has been changed to protect patient confidentiality. This piece was written as part of the Partnership for Physician Advocacy Skills program at UCSF.
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