Perspectives on the ethical concerns and justifications of the 2006 Centers for Disease Control and Prevention HIV testing: HIV screening policy changes.

BACKGROUND: The 2006 Centers for Disease Control and Prevention (CDC) revised recommendations for HIV testing in clinical settings contained seven specific changes to how health care facilities should provide HIV testing. These seven elements have been both supported and challenged in the lay and medical literature. Our first paper in BMC Medical Ethics presented an analysis of the three HIV testing procedural changes included in the recommendations. In this paper, we address the four remaining elements that concern HIV screening policy changes: (1) nontargeted HIV screening, (2) making HIV screening similar to screening for other treatable conditions, (3) increasing HIV screening without assured additional funding for linkage to care, and (4) making patients bear the costs of increased HIV screening in health care settings. METHODS: We interviewed 25 members from the fields of US HIV advocacy, care, policy, and research about the ethical merits and demerits of the four changes to HIV screening policies. We performed a qualitative analysis of the participant responses in the interviews and summarized the major themes. RESULTS: Participants commented that nontargeted HIV screening and making HIV screening similar to screening for other treatable medical conditions was ethical when it broadened the scope of people being tested for HIV. However, they believed it was unethical when it did not respect the exceptional nature of HIV and HIV testing. Some participants favored more testing regardless if there was assured additional funding for linkage to care or if patients might bear the costs of testing because they believed that merely alerting patients of their status was beneficial and would lead to positive consequences. Other participants found ethical flaws with testing without assured linkage to care and patients bearing the costs of testing, as this could discriminate against those who could not pay. CONCLUSIONS: Our findings suggest that there are fundamental ethical disagreements that shape views on CDC's recommended HIV testing policies. Differences remain on whether or not HIV remains an exceptional condition that requires it to be treated differently than other treatable conditions. Disagreement also exists on the responsibilities of health care providers and rights of patients in regards to screening in (1) the absence of assured linkage to care after an HIV diagnosis and (2) paying for the costs of HIV screening. Resolution of these disagreements is needed to serve the common goal of using testing to facilitate medical care for those who are HIV infected and for reducing HIV transmission.

Patient and clinician ethical perspectives on the 2006 Centers for Disease Control and prevention HIV testing methods.

OBJECTIVES: CDC 2006 recommendations for new HIV testing methods in U.S. health-care settings (opt-out approach, general medical consent, and optional prevention counseling) have been the subject of a public ethical debate. Ethical concerns might limit their implementation and affect expanded HIV screening efforts. We compared clinicians' and patients' perspectives on the ethical concerns raised about, justifications provided in support of, and preferences for the 2006 CDC-recommended HIV testing methods for the U.S. health-care setting, in contrast with the 2001 CDC-recommended HIV testing methods (opt-in approach, specific written consent, and mandatory prevention counseling). METHODS: We conducted a non-inferiority trial and survey of 249 clinicians and random samples of 1,013 of their patients at three emergency departments and three ambulatory care clinics at university-affiliated hospitals in Rhode Island from June to December 2007. RESULTS: Clinicians found the 2006 CDC HIV testing methods to be more ethically concerning than the 2001 testing methods (i.e., ethically inferior), while patients had few ethical concerns. In regard to ethical justifications cited for the 2006 CDC HIV testing methods, clinicians were more supportive of the ethical justifications cited for using an opt-out approach and general medical consent, while patients were more supportive of the justifications for optional HIV prevention counseling. Clinicians showed a relatively greater preference for the opt-out approach and use of general medical consent, while patients had a relatively greater preference for optional HIV prevention counseling. CONCLUSIONS: Clinicians and their patients hold divergent ethical perspectives on CDC's 2006 HIV testing methods. The results indicate an opportunity to review not only these but also future HIV testing recommendations, as well as how they are presented for implementation.

Perspectives on the ethical concerns and justifications of the 2006 Centers for Disease Control and Prevention HIV testing recommendations.

BACKGROUND: In 2006, the Centers for Disease Control and Prevention (CDC) recommended three changes to HIV testing methods in US healthcare settings: (1) an opt-out approach, (2) removal of separate signed consent, and (3) optional HIV prevention counseling. These recommendations led to a public debate about their moral acceptability. METHODS: We interviewed 25 members from the fields of US HIV advocacy, care, policy, and research about the ethical merits and demerits of the three changes to HIV testing methods. We performed a qualitative analysis of the participant responses in the interviews and summarized the major themes. RESULTS: In general, arguments in favor of the methods were based upon their ultimate contribution to increasing HIV testing and permitting the consequent benefits of identifying those who are HIV infected and linking them to further care. CONCLUSIONS: The prevailing theme of ethical concern focused on suspicions that the methods might not be properly implemented, and that further safeguards might be needed.

An ethical evaluation of the 2006 Centers for Disease Control and Prevention Recommendations for HIV testing in health care settings.

When in 2006 the Centers for Disease Control and Prevention issued revised recommendations for HIV testing in health care settings, vocal opponents charged that use of an "opt-out" approach to presenting HIV testing to patients; the implementation of nontargeted, widespread HIV screening; the elimination of a separate signed consent; and the decoupling of required HIV prevention counseling from HIV testing are unethical. Here we undertake the first systematic ethical examination of the arguments both for and against the recommendations. Our examination reveals that the ethical concerns raised by the critics predominantly pertain not to ethically suspect elements of the recommendations themselves, but to suspicions that they will be implemented improperly. It has not been shown that the recommendations cannot be implemented properly. Here we show that in the United States the recommendations are morally justifiable and that safeguards or regulatory oversight may serve to ensure that the recommendations are properly implemented.