Public Health Principles for the HIV Epidemic
http://www.100md.com
《新英格兰医药杂志》
To the Editor: We commend the call by Frieden et al. (Dec. 1 issue)1 for a comprehensive public health approach to the epidemic of human immunodeficiency virus (HIV) infection. The authors' lack of evidence with regard to the relative impact of their case-finding approach, however, raises questions about the scientific basis for their conclusions. Given that there is considerable stigma against injection-drug users, men who have sex with men, and sex workers in many localities and institutions, it is important to evaluate whether the case-finding techniques would increase stigmatization of those at risk and thereby weaken HIV-prevention efforts among stigmatized and fearful risk groups. Injection-drug users in New York City began reducing their high-risk behavior before AIDS was identified in 1981, and their effective efforts to minimize risk and to communicate methods of risk reduction still continue.2,3,4 Organizing on the part of homosexual men since the early days of the HIV epidemic has contributed to far-reaching effects on policy, high-risk behavior, and community norms.5 Before the case-finding proposals of Frieden and colleagues are implemented, research should determine whether they would weaken the prevention efforts of the populations at risk.
Samuel R. Friedman, Ph.D.
National Development and Research Institutes
New York, NY 10010
friedman@ndri.org
Susan G. Sherman, Ph.D., M.P.H.
Johns Hopkins Bloomberg School of Public Health
Baltimore, MD 21205
References
Frieden TR, Das-Douglas M, Kellerman SE, Henning KJ. Applying public health principles to the HIV epidemic. N Engl J Med 2005;353:2397-2402.
Friedman SR, Curtis R, Neaigus A, Jose B, Des Jarlais DC. Social networks, drug injectors' lives, and HIV/AIDS. New York: Kluwer Academic, 1999.
Friedman SR, Maslow C, Bolyard M, Sandoval M, Mateu-Gelabert P, Neaigus A. Urging others to be healthy: "intravention" by injection drug users as a community prevention goal. AIDS Educ Prev 2004;16:250-263.
Des Jarlais DC, Perlis T, Arasteh K, et al. "Informed altruism" and "partner restriction" in the reduction of HIV infection in injecting drug users entering detoxification treatment in New York City, 1990-2001. J Acquir Immune Defic Syndr 2004;35:158-166.
Kippax S, Race K. Sustaining safe practice: twenty years on. Soc Sci Med 2003;57:1-12.
To the Editor: Hurray for Frieden et al. for clearly elucidating the need for applying public health principles to the HIV epidemic. As the authors point out, routine HIV testing as part of primary care is indicated on the basis of clinical efficacy and cost-effectiveness.1,2,3 Routine HIV testing is now recommended for all pregnant women as part of their prenatal care, irrespective of perceived risk.4 Written informed consent is a barrier to the implementation of these recommendations. Although written informed consent was necessary in the past, improved knowledge of HIV and AIDS and current legal protections make such consent unnecessary and burdensome in most settings. Although HIV testing should be routine in a myriad of settings, it should not be mandatory or coerced. Oral informed consent for HIV testing (as is standard for testing for other sexually transmitted diseases) is appropriate. States should consider changing HIV-related regulations to do away with mandatory written informed consent.
Timothy P. Flanigan, M.D.
Curt Beckwith, M.D.
Charles C.J. Carpenter, M.D.
Brown Medical School
Providence, RI 02906
tflanigan@lifespan.org
References
Sanders GD, Bayoumi AM, Sundaram V, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med 2005;352:570-585.
Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States -- an analysis of cost-effectiveness. N Engl J Med 2005;352:586-595.
Bozzette SA. Routine screening for HIV infection -- timely and cost-effective. N Engl J Med 2005;352:620-621.
Preventive Services Task Force. Screening for HIV: recommendation statement. Ann Intern Med 2005;143:32-37.
The authors reply: Increased detection of HIV infection benefits infected persons, their contacts, and the community. When HIV infection is diagnosed before the onset of clinical illness, patients can decide when to start treatment and can avoid serious complications. Patients who receive a diagnosis late in their illness are much more likely to die within a year of diagnosis1; those who know they are infected reduce risky behavior by about half.2
There is no evidence that a standard offer of voluntary HIV testing as part of normal medical care will increase stigma. Indeed, persons may well encounter reduced discrimination if voluntary testing is offered universally in health care settings.
The stigma of an HIV diagnosis can be devastating, but the alternative — not getting care, spreading infection to others, continuing to encounter stigma, and dying prematurely of AIDS — is even worse. A generation ago, cancer was stigmatized; it is now markedly less so owing to increased identification of cases, improved treatment, and public education. We concur with Friedman and Sherman that more research and action are needed to mitigate the serious problem of HIV-related stigma.
We agree with Flanigan et al. that written consent for HIV testing now represents a major and unnecessary barrier to helping patients voluntarily learn their HIV status. State laws requiring written consent separate from the general consent for medical diagnosis and treatment should be changed.
Thomas R. Frieden, M.D., M.P.H.
Scott E. Kellerman, M.D., M.P.H.
Moupali Das-Douglas, M.D.
New York City Department of Health and Mental Hygiene
New York, NY 10013
tfrieden@health.nyc.gov
References
Chadborn TR, Baster K, Delpech VC, et al. No time to wait: how many HIV-infected homosexual men are diagnosed late and consequently die? (England and Wales, 1993-2002). AIDS 2005;19:513-520.
Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr 2005;39:446-453.
Samuel R. Friedman, Ph.D.
National Development and Research Institutes
New York, NY 10010
friedman@ndri.org
Susan G. Sherman, Ph.D., M.P.H.
Johns Hopkins Bloomberg School of Public Health
Baltimore, MD 21205
References
Frieden TR, Das-Douglas M, Kellerman SE, Henning KJ. Applying public health principles to the HIV epidemic. N Engl J Med 2005;353:2397-2402.
Friedman SR, Curtis R, Neaigus A, Jose B, Des Jarlais DC. Social networks, drug injectors' lives, and HIV/AIDS. New York: Kluwer Academic, 1999.
Friedman SR, Maslow C, Bolyard M, Sandoval M, Mateu-Gelabert P, Neaigus A. Urging others to be healthy: "intravention" by injection drug users as a community prevention goal. AIDS Educ Prev 2004;16:250-263.
Des Jarlais DC, Perlis T, Arasteh K, et al. "Informed altruism" and "partner restriction" in the reduction of HIV infection in injecting drug users entering detoxification treatment in New York City, 1990-2001. J Acquir Immune Defic Syndr 2004;35:158-166.
Kippax S, Race K. Sustaining safe practice: twenty years on. Soc Sci Med 2003;57:1-12.
To the Editor: Hurray for Frieden et al. for clearly elucidating the need for applying public health principles to the HIV epidemic. As the authors point out, routine HIV testing as part of primary care is indicated on the basis of clinical efficacy and cost-effectiveness.1,2,3 Routine HIV testing is now recommended for all pregnant women as part of their prenatal care, irrespective of perceived risk.4 Written informed consent is a barrier to the implementation of these recommendations. Although written informed consent was necessary in the past, improved knowledge of HIV and AIDS and current legal protections make such consent unnecessary and burdensome in most settings. Although HIV testing should be routine in a myriad of settings, it should not be mandatory or coerced. Oral informed consent for HIV testing (as is standard for testing for other sexually transmitted diseases) is appropriate. States should consider changing HIV-related regulations to do away with mandatory written informed consent.
Timothy P. Flanigan, M.D.
Curt Beckwith, M.D.
Charles C.J. Carpenter, M.D.
Brown Medical School
Providence, RI 02906
tflanigan@lifespan.org
References
Sanders GD, Bayoumi AM, Sundaram V, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med 2005;352:570-585.
Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States -- an analysis of cost-effectiveness. N Engl J Med 2005;352:586-595.
Bozzette SA. Routine screening for HIV infection -- timely and cost-effective. N Engl J Med 2005;352:620-621.
Preventive Services Task Force. Screening for HIV: recommendation statement. Ann Intern Med 2005;143:32-37.
The authors reply: Increased detection of HIV infection benefits infected persons, their contacts, and the community. When HIV infection is diagnosed before the onset of clinical illness, patients can decide when to start treatment and can avoid serious complications. Patients who receive a diagnosis late in their illness are much more likely to die within a year of diagnosis1; those who know they are infected reduce risky behavior by about half.2
There is no evidence that a standard offer of voluntary HIV testing as part of normal medical care will increase stigma. Indeed, persons may well encounter reduced discrimination if voluntary testing is offered universally in health care settings.
The stigma of an HIV diagnosis can be devastating, but the alternative — not getting care, spreading infection to others, continuing to encounter stigma, and dying prematurely of AIDS — is even worse. A generation ago, cancer was stigmatized; it is now markedly less so owing to increased identification of cases, improved treatment, and public education. We concur with Friedman and Sherman that more research and action are needed to mitigate the serious problem of HIV-related stigma.
We agree with Flanigan et al. that written consent for HIV testing now represents a major and unnecessary barrier to helping patients voluntarily learn their HIV status. State laws requiring written consent separate from the general consent for medical diagnosis and treatment should be changed.
Thomas R. Frieden, M.D., M.P.H.
Scott E. Kellerman, M.D., M.P.H.
Moupali Das-Douglas, M.D.
New York City Department of Health and Mental Hygiene
New York, NY 10013
tfrieden@health.nyc.gov
References
Chadborn TR, Baster K, Delpech VC, et al. No time to wait: how many HIV-infected homosexual men are diagnosed late and consequently die? (England and Wales, 1993-2002). AIDS 2005;19:513-520.
Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr 2005;39:446-453.