The U.S. Food and Drug Administration (FDA) approved the first test to determine the presence of HIV antibodies in humans, enzyme-linked immunosorbent assay, or ELISA, in 1985. That year, there were 5,636 deaths in the United States attributable to AIDS. The FDA approved the Western Blot, a test to confirm HIV infection, in 1986—a year in which 2,630 Americans are reported to have died from AIDS. In 1987, the FDA approved AZT (zidovudine, or Retrovir) as the first drug to treat HIV/AIDS; there were 4,135 deaths in the United States attributable to AIDS that same year. In 2002, the FDA approved the first HIV “rapid test” for use in this country. Unlike results from an ELISA, which take several days to receive, “rapid test” results are available in twenty minutes. By 2006, the FDA had approved nearly a half-dozen “rapid tests” for HIV screening and more than two dozen drugs to treat HIV. And that year, approximately 56,300 Americans were newly infected.
HIV infects white blood cells known as CD4+ cells, which are part of the body’s immune system that help fight infections. An HIV test detects antibodies to HIV or the genetic material (DNA or RNA) of HIV in the blood or another type of sample. If the test reveals that HIV infection is present (i.e., one is HIV-positive), confirmatory tests are required. HIV testing in the early years was characterized by legal requirements for specific, written, informed consent; anonymity; recommendations for significant pre- and post-test counseling; and, too often, lack of follow-up care.
Some cities in the United States have been harder hit by HIV than others. As of 2008, 3 percent of the residents in the nation’s capital of Washington, D.C., were known to be living with HIV/AIDS, a rate three times higher than the definition of a generalized and severe HIV epidemic as defined by the U.S. Centers for Disease Control and Prevention (CDC). Oakland, California, is home to a half-million people on the east side of the San Francisco Bay. In Oakland and surrounding Alameda County, more than 7,000 AIDS cases were diagnosed among residents from 1980 to 2006. The majority were either African American (44 percent) or white (42 percent), male (86 percent), and adults ages 30 to 49 years (71 percent). Los Angeles is the second largest city in the United States, with a population of more than 3.7 million people. Estimates suggest that approximately 30,000 people in the City of Los Angeles are living with AIDS or HIV—including those who do not yet know they are infected. Houston/Harris County, Texas, had an AIDS rate of 17.8 percent in 2007. Houston’s annual rate in new HIV infections is nearly twice the national average, and although blacks and Latinos account for only 60 percent of Houston’s population in 2006, they made up 78 percent of the city’s HIV cases. Miami-Dade is located in southeastern Florida. According to the regionally based Care Resource, the Miami metropolitan area has the highest AIDS rate in the nation at 52.8 percent. It is experiencing a generalized epidemic with nearly 1.5 percent of the population of Miami living with HIV or AIDS.
More than 100,000 New Yorkers are living with HIV. New York City has the highest AIDS case rate in the country, with more AIDS cases than Los Angeles, San Francisco, Miami, and Washington, D.C., combined. Each year, more than 1,000 people in New York City first find out they are HIV-positive when they are already sick with AIDS and 80 percent of new AIDS diagnoses and deaths are among African Americans and Hispanics. In 2004, the Bronx, one of New York City’s five boroughs, was the poorest of America’s 435 congressional districts. The death rate from HIV in the Bronx is higher than in the rest of New York City, and a growing number of people in the Bronx (40 percent) who find out they are positive, find out the same day that they have AIDS.
American Cities Take Action
In 2006, the Department of Health in Washington, D.C., launched an aggressive HIV testing initiative to encourage all citizens between the ages of 14 and 84 to get tested for HIV. The initiative, Come Together DC—Get Screened for HIV, was the first municipal HIV testing initiative in the United States. City leadership got the community involved at the outset—government leaders, health and civic, community and government, clinics and hospitals—all were engaged; faith-based leaders were an important part of the conversation. City officials called stakeholders in for a meeting with physicians. In addition to local philanthropists, the city involved the corporate sector, 75 percent of whom are academic institutions, hospitals, and clinics. And D.C. developed a system for monitoring and evaluating the data.
Also in 2006 the CDC published Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings, which called for routine screening in medical settings of all patients between the ages of 13 and 64. And while the recommendations were for health-care providers, physicians, and public health officials, AIDS service organizations and HIV advocacy organizations throughout the United States raised serious objections to the recommendations and their planned implementation. As a result of the protests and confusion over some “controversial” issues, including informed consent and mandatory screening, the aforementioned recommendations were largely ignored. In the meantime, the epidemic continued unabated, while the HIV testing recommendations were put on the shelf and ignored.
Then, in the summer of 2008, the CDC released new data showing an increase in annual HIV transmissions from an average of 40,000 new infections a year to more than 56,000 new infections. With the publication of the revised estimates of HIV transmission, many in the HIV community and health sector began to rethink the need for expanded HIV testing and to develop strategies to implement the CDC’s revised recommendations. Municipal-level, citywide HIV testing—following the lead set by Washington, D.C., in 2006—has emerged as one such strategy.
Between 2006 and 2009, the high-impact jurisdictions of Oakland, Los Angeles, Houston, Miami/Dade County, and the Bronx joined Washington in scaling up HIV testing. Get Screened Oakland, Test LA—Erase Doubt.Org, Hip-Hop for HIV Test, Test Miami, and The Bronx Knows, the current municipal HIV testing scale-up initiatives in the United States, all strive to educate their citizens about HIV infection, retool public health agencies, and involve all sectors in the community in citywide public health education and macro intervention efforts.
The premise behind the municipal HIV testing initiatives is that HIV is a virus, transmission is preventable, and lifesaving medicines are available for those requiring treatment. Screening for HIV is necessary to detect the presence of the virus and to determine whether transmission/infection has occurred and whether and when to start treatment. The health sector, at the very least, should be testing people for the presence of the infectious virus, and for those whose test result is positive, engaging in treatment. To that end, U.S. Department of Health and Human Services agencies including the CDC, in partnership with the National Institutes of Health and the Health Resources Services Administration, funded a two-day think tank in late 2009 entitled Test and Treat. Why? Because, after nearly three decades, it’s now commonly accepted that HIV testing should be a routine component of regular health care. People who require treatment should have universal access to lifesaving medications regardless of where she or he might live.
The intervening premise is that people who know their HIV status tend to make healthier decisions. An estimated one-quarter of all individuals infected with HIV in the United States are unaware of their HIV status. Data shows that the majority of new infections result from those individuals who are unaware of their HIV status. Routine testing for HIV helps to bridge the gap between those who know their HIV serostatus and those who do not—making it easier to begin to control and prevent the spread of the virus. The summary premise is that public health evidence suggests that people who are HIV positive and are aware of their HIV serostatus are less likely to transmit the virus to others. HIV testing is the key to disease control and prevention.
As a result of these innovative HIV testing initiatives and the new CDC guidelines, the public health goals and human rights and protections of the 1980s and 1990s have necessarily been re-engineered to better respond to the realities of the HIV epidemic today. In many countries, states, and counties, informed consent laws have been revised and changed. Confidential testing and name-based reporting have replaced anonymous testing and code-based reporting. “Opt-out” testing has replaced “opt-in” testing. Risk-based targeted testing has been replaced by offering HIV testing to everyone regardless of traditionally thought-of risk factors. Pre- and post-test counseling processes have been abbreviated and HIV testing algorithms have been adapted to support rapid HIV testing protocols that reveal HIV serostatus in 15 to 30 minutes. CD4 counts of 350 have replaced CD4 counts of 200 as the recommended indication of the need for treatment. Lifesaving medications are more readily available in many communities. And the new “combination” of testing, education, treatment, and prevention interventions is believed to contribute to the reduction in the rate of HIV in communities.
Municipal HIV testing initiatives are community engagement programs that work. Under the auspices of the highest elected official, such as mayor, health department director, or provincial, district, or county leader, municipal HIV testing initiatives bring renewed attention and leadership to HIV in the community. At a time when many communities, agency leaders, and advocates voice concern about HIV fatigue, municipal engagement brings an infusion of untapped energy, renewed dedication, and new opportunities for collaboration. Washington, Oakland, Los Angeles, Houston, Miami, and the Bronx all increased HIV testing between 20 and 50 percent in the first year of their initiatives.
Planning a Municipal HIV Testing Initiative
With leadership in hand, all segments of the community can become involved and re-engaged and increase the public health effectiveness of the local HIV/AIDS strategy. What follows is a suggested implementation framework checklist for planning a municipal HIV testing initiative.
• Think tank–style meeting—convene community leaders to assess and review current HIV agenda, laws, and regulations, envision change, and develop plan of action.
• Implementation task force/workgroup—identify community stakeholders to provide expertise and guidance on challenges associated with the municipal initiative.
• Community engagement plan—recruit community-based organizations, public health partners, advocacy organizations, philanthropic resources, and faith-based and private-sector leadership to assist with implementation.
• Social marketing strategy and media outreach—identify paid and pro bono public relations and media partners in order to develop an effective media strategy including web-based promotions; radio, television, and video opportunities; and public venue banners, palm cards, brochures, transportation-related ad placements, billboards, and other outdoor possibilities.
• Private-sector outreach and engagement—reach out to largest employers and private-sector corporate partners for in-kind resources and ongoing community support for HIV testing, prevention, and awareness.
• HIV-testing technical education and training—develop a testing protocol and conduct training prior to implementing the municipal initiative.
• Clinic, health center, and hospital workgroup—convene regularly scheduled meetings of the health sector in order to streamline HIV testing and enhance HIV treatment services and support.
• Data collection, monitoring, and evaluation—ensure constant program monitoring and evaluation of the initiative by partnering with current and new testing sites through the development of memoranda of understanding.
• Announcement of municipal HIV testing initiative goals—such as to make HIV testing a routine component of regular health care; identify new cases and reduce “late testing;” raise awareness about the importance, availability, and ease of HIV testing; reduce HIV transmission; and link HIV-positive persons to regular and ongoing HIV care and treatment.
It has been said that HIV is the only infectious disease that has been left to the community to identify, treat, and manage. HIV is a virus requiring medical attention and intervention, is it not? Why, then, is it acceptable for health-care providers to ignore it? Where are the human rights protections when trained health-care providers ignore guidelines and recommendations? HIV screening is for everyone, even health-care providers. They must offer the test, protect human life, and in doing so, affirm everyone’s human rights. It is the humane thing to do.