Aggressive cancer screenings leading to over-diagnoses and unnecessary treatments have been the subject of recent controversy. In stark contrast, HIV, another life-threatening illness, continues to be under-diagnosed, and efforts to test and treat persons at greatest risk are failing, resulting in a nation struggling to end an epidemic.
An HIV test -- a mouth swab -- is easy and relatively cheap. Available treatments for HIV can virtually stop its progress, particularly if begun before serious immune suppression. This is the kind of treatment we ached to offer our friends who died in the earlier years of the epidemic. Now we have the "magic pills" we longed for but still struggle to get those at greatest risk tested and linked to care. So with more than 1 million people living with HIV in the U.S. and 50,000 new infections each year, why are populations most at risk not being tested?
The stigma associated with the disease is one reason, but it is only partially to blame for this public health failure. More problematic is the difficulty of reaching the most vulnerable members of the U.S. population who are living with HIV but unaware of their status: racial and ethnic minorities, the poor and disenfranchised, and people who are homeless. These are people who are less likely to be connected to health care professionals and thus less likely to be tested for HIV and linked to care. Included in this group are African-American and Hispanic men who have sex with men. They are the people who are most dramatically affected by this disease. These men -- already marginalized by a society that discriminates against them -- are even more reluctant to get tested, fearing both the test and the results will only increase discrimination.
So how do you reach these people who rarely visit a doctor? And if you are able to find them, how do you convince them that an HIV test presents an opportunity to preserve their health and prevent transmission of HIV to others?
Effective testing strategies and innovative outreach hold the promise of closing the gap that perpetuates the spread of HIV in communities nationwide. When people know their status, they are more likely to take precautions when having sex. Further, early initiation of HIV therapy dramatically reduces the likelihood of transmitting HIV because the HIV drugs reduce the amount of virus in bodily fluids.
Recently, the government intensified efforts in the U.S. to increase HIV testing, particularly in cities with the highest prevalence. Although this is a move in the right direction, many initiatives rely heavily on targeting persons in clinical settings, offering tests to persons treated in emergency rooms, for example. While it's smart to focus on people who have contact with providers, this method misses those who are not connected to the medical system. That's why more resources are needed for creative outreach strategies, focusing on those at highest risk and not waiting for them to come to doctors' offices.
The Centers for Disease Control and Prevention (CDC) has recently provided more resources to community-based organizations and health departments, helping them scale up networking strategies, for example, where recently-diagnosed persons encourage their friends and acquaintances to be tested, or mobile testing vans, where testing sites come directly to people where they live, work and socialize. The CDC is also piloting outreach programs that employ at-home testing kits. Programs like these have been demonstrated to better reach populations that don't participate in traditional screening programs.
However, as innovative as these programs are, they are not adequate. Until we as a nation devote the same passion to HIV screening and access to care as we do to other types of screenings, we will continue to fall short in our goal of ending this epidemic. We have the tools to dramatically change the course of HIV now, to save thousands of lives and prevent countless future infections. The question is whether we have the will to employ these tools creatively and vigorously in order to prevail.
Scott Royal, Ph.D., is vice president of the U.S. Health Division at Abt Associates in Bethesda, Md. and Emeritus Board Member of Metro TeenAIDS.