Laws No Longer a Barrier to Universal HIV Testing in Most States, UCSF Reports

According to an article by researchers at the University of California, San Francisco (UCSF) and San Francisco General Hospital and Trauma Center (SFGH), some 45 to 50 states and the District of Columbia have new or existing laws that explicitly agree with CDC recommendations that doctors offer HIV testing as a routine part of health care for all people aged 13 to 64.

The CDC recommends such “universal” testing because hundreds of thousands of Americans have undiagnosed infection with HIV. Earlier diagnoses would allow doctors to begin administering treating earlier too, which could significantly extend lives. Earlier diagnoses could also help prevent further spread of infection.

Misunderstandings about state laws, however, have been one barrier to routine HIV/AIDS testing. Some doctors may not offer the tests to their patients out of uncertainty about how state privacy laws may impact their ability to do so.

Twenty-four states have changed their laws in recent years to address this problem. As detailed in the journal JAMA this week, newly passed or existing legislation in the District of Columbia and 45 states, including California, make those states’ laws compatible with the CDC recommendations. The exceptions are Massachusetts, Nebraska, New York, Pennsylvania and Rhode Island – where laws conflict in some respect with the CDC’s recommendations.

The bottom line, said Sarah Neff, MPH, the study’s lead author, is that “HIV testing laws in most states no longer present a barrier to routine testing.”

“Clinicians should understand that they don’t have to be worried about state laws being an impediment to testing,” said Neff, who is the director of research and evaluation at the National HIV/AIDS Clinicians’ Consultation Center. She conducted the survey of state laws with Ronald Goldschmidt, MD, the center’s director.

Based at San Francisco General Hospital and operated by the UCSF Department of Family and Community Medicine at SFGH, the National HIV/AIDS Clinicians’ Consultation Center is a clearinghouse of information and clinical resources for health care professionals worldwide, including an online Compendium of State HIV Testing Laws.

Recommendations Made in 2006

More than a million Americans are estimated to be living with HIV/AIDS, and about 21 percent of them have undiagnosed infections, according to the CDC.

To help identify the hundreds of thousands of people in the United States with undiagnosed HIV/AIDS, the CDC set current recommendations for diagnostic HIV testing in 2006, calling for doctors to routinely offer testing to all patients aged 13 to 64. This was a fundamental shift from earlier CDC recommendations, which had called for targeted “risk-based” testing.

When it first made the new recommendation five years ago, the CDC explicitly recognized several barriers to universal testing, including the cost – (now around $10-$15 per test). One of the biggest perceived barriers in 2006 was the legal authority for testing.

Laws governing HIV/AIDS testing, privacy and consent fall under the jurisdiction of each state and the legal landscape in 2006 was a confusing patchwork of laws that varied from state to state. In the end, Neff said, many doctors ended up confused about how their own state laws may or may not have allowed them to comply with the CDC recommendations. Unsure, many opted not to offer HIV tests to their patients.

As Neff and Goldschmidt detail in their paper, however, 24 states have passed laws in the last few years to bring their laws in line with the CDC guidelines. Now, according to the UCSF tally, only five states have some level of conflict.

All five have considered and wrestled with the issue in the past few years but have either failed to change their laws or have deliberately retained aspects of their laws that conflict with the CDC recommendations.

In Massachusetts, for instance, legislators have introduced bills in the last two legislative sessions to change the laws, but the bills failed both times. New York has passed legislation to bring its laws into agreement with the CDC recommendations in some ways but not in others.

“Because the overall goal is to ensure the maximal number of HIV-infected patients know their diagnosis, so they can receive treatment and not infect others, the removal of state law obstacles is an important advance in testing,” Neff said.   

The National HIV/AIDS Clinicians’ Consultation Center is affiliated with the AIDS Research Institute (ARI) at UCSF, which draws together hundreds of scientists and dozens of programs throughout UCSF and affiliated labs and institutions, making ARI one of the largest AIDS research entities in the world.

The National HIV/AIDS Clinicians’ Consultation Center has received support from the Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA), neither of which contributed to this study.