Path: utzoo!utgpu!news-server.csri.toronto.edu!cs.utexas.edu!sun-barr!olivea!samsung!usc!ucla-cs!usenet
From: ST602662%BROWNVM.BITNET@mvs.oac.ucla.edu (Bill Jesdale)
Newsgroups: sci.med.aids
Subject: Re: (3248)  Legislation for AIDS
Message-ID: <1991Jun20.181845.6628@cs.ucla.edu>
Date: 20 Jun 91 15:25:50 GMT
Sender: usenet@cs.ucla.edu (Mr. News Himself)
Organization: UCLA, Computer Science Department
Lines: 88
Approved: phil@wubios.wustl.edu
Note: non-commercial reproduction.
Nntp-Posting-Host: squid.cs.ucla.edu
Archive-Number: 3272

I will describe a program we have in Rhode Island.

Basically, it is a compromise between the groups lobbying for widespread
anonymous testing (myself included) and the mandatory testing folks.

In Rhode Island, by law, every person making a family planning, pre-natal,
pre-marital, or STD visit is required to be offered HIV testing after
discussing the pros and cons of testing with a qualified counselor.
  An earlier version of the law required such offering to hospital
inpatients, but the program was found to be extremely cost-inefficient
in a matter of months, and was scrapped.

Good points of this plan:
RAISING THE ISSUE:
   It helps 'normalize' talking about HIV. Nurses and other health care
   workers can raise the issue without coming off as 'passing judgement,'
   because the counseling is mandated by law, not out of perception of
   personal risk.
   It presents HIV infection as a serious issue for a large number of
   persons who might not otherwise give it much thought, and affords
   them an opportunity to ask questions which they might well be
   reluctant to bring up on their own.
   Raising the issue goes both ways -- It is just as important to make
   health care workers learn about HIV infection and to feel comfortable
   discussing it, and related issues, as it is for clients of these
   agencies.
FREEDOM TO CHOOSE
   One of the most important aspects of this program is that people are
   allowed to choose whether or not they would like to be tested. This
   is essential not only because mandatory testing is a frought with
   personal liberty issues, but also because it puts the burden of proof
   on the health care worker to convince a person s/he ought (or not) to be
   tested, which helps to ensure that the client is making a more fully
   informed choice.
PUBLIC HEALTH BENEFITS
   Some would argue that the more people who know their HIV status, the
   more successful efforts to stop transmission will be. I'm not sure I
   agree with this rationale, but I think that the more people who _want_
   to know their HIV status who can do so easily, the better.
   The counseling session, ideally, should help to sort out what an
   individual's risk behaviors have been/will likely be, and to use that
   information to plan an individual prevention plan, whether that person
   already knows their HIV status, wants to know it, or not. If all the
   people getting the counseling about HIV testing are taken one step
   closer to setting up a viable prevention plan for themselves, then a
   world of good has been done, even if nobody gets tested.
HIGH TESTING RATE
   While some in the RI Department of Health might disagree with me, I
   feel that the rate of testing we're getting through this program is
   pretty high, given the distribution of risk factors, and the likely
   seroprevalence of HIV in the state. Very few (around 10-15) have
   tested positive in the first year and a half of the program, which
   is a good sign. The incremental benefit (so-called) of mandatory
   testing (which would capture mainly people at very low risk, or
   people who already have been tested at another site) would be
   pretty low.

Not so good aspects:
INFORMED CONSENT?
   In practice, it isn't always clear that people are choosing to be
   tested of their own free will. It isn't clear that they really
   understand what the test means, and my big beef is that most aren't
   made aware of the anonymous testing option.
CONFIDENTIAL NOT ANONYMOUS
   This program is run on a confidential basis, which basically means that
   your results are attached to your name, and nobody can legally tell
   anyone else, _except_ for about a dozen or so exceptions to the
   confidentiality law. It also does not prevent _illegal_ disclosure
   (which can be damaging once done, and can be very difficult to fight
   anonymously through the courts).
   Anonymous testing means you never give your name, and thus unless one
   of the workers in the office knows you personally, you are essentially
   protected even from illegal disclosure (until you need to seek medical
   attention, but at least there's a somewhat greater feeling of control
   about the situation)
COST EFFECTIVENESS
   Some argue that it's just not cost effective to do all this counseling
   and testing of people, most of whom are at very low risk of infection.
   They argue that a public health promotion campaign of education is a
   better way to spend money. I counter that this program is an education
   campaign, but I will also quickly concede that I feel that the RIDH
   has slacked off on its public education efforts since this program
   went into effect, and it cannot be a susbstitute for the former.

Hope this helps,
  Bill Jesdale
  BRUNAP, Box G-S204, Brown U, Prov RI 02912
  (401) 863-1975