Federal health officials, advocating a significant expansion of AIDS testing policy, proposed Wednesday that all patients entering hospitals be routinely encouraged to undergo screening for infection with the human immunodeficiency virus.
The proposed guidelines, which are certain to be controversial, mark the first time that the federal government has formally moved to urge testing among hospital patients not necessarily considered at risk for AIDS infection. A similar suggestion by several public health officials in 1987 was abandoned, along with a proposal to test all applicants for marriage licenses.
The guidelines, which were drafted and released by the federal Centers for Disease Control in Atlanta, would not be mandatory. Even so, they are expected to have a major impact on the practices of public and private hospitals and on state and local health departments across the country.
"We are not recommending mandatory testing, but we are suggesting that we treat HIV today the way syphilis was treated in the past," said Dr. James O. Mason, assistant secretary for health, in an interview. "Years ago, patients were routinely tested for syphilis as part of a hospital workup."
The guidelines stressed, however, that HIV testing should be conducted only with the informed consent of the patient, and would be accompanied by counseling so that patients fully understand the implications of the results.
Even with those precautions, Mason said that he expected the recommendations would evoke considerable opposition from "people who don't like testing and who want as little testing as possible."
Health officials said they hoped that such testing would enable infected patients to receive early medical intervention, and would protect health care workers who might be exposed to infected patients. Recently, the CDC also issued guidelines recommending testing of health professionals who perform surgery.
Although the Public Health Service has for some years recommended testing of individuals who engage in high-risk activities known to transmit the AIDS virus, they said Wednesday that many people are likely to be unknowingly infected and would benefit from screening.
In addition, a number of treatments are now available that have proved successful in slowing the onset of fully developed AIDS in infected individuals, such as therapy with the antiviral drug AZT, also known as zidovudine. Treatment with several other drugs is known to prevent episodes of pneumocystis carinii pneumonia , a life-threatening respiratory ailment that is common to AIDS patients and often signifies the onset of the disease.
"So many people test positive and it comes as a total surprise to them," Mason said. "If we really have 1 million people out there who are infected, these people ought to be identified for their own good. This is the overriding consideration that is driving this. If I were HIV positive, I would want to know."
The guidelines recommend that hospitals and their associated health-care providers routinely offer and encourage HIV testing for all patients.
Such services "are especially indicated for patient populations with an HIV (prevalence) of greater than 1%." In hospitals where AIDS prevalence is very low, "services could be provided to patients within a defined age range," in other words, those patients whose age puts them at greater risk for infection.
"The results should be provided in a confidential manner," the proposed guidelines state. "HIV-infected persons should receive medical evaluation for their HIV infection and specific therapies and prevention services as needed."
Jeff Levi, director of government affairs for the Washington-based AIDS Action Council, said he feared that counseling and early intervention could not accompany such large-scale testing without additional federal resources.
"There are 33 million hospital admissions every year," he said. "If you test all at, for example, $50 a pop, that's $1.6 billion a year. Who's going to pay that bill?"
Federal health officials, who previously have urged health care workers to follow "universal precautions" to decrease their risk of infection, warned that HIV testing of patients should not be used as a substitute for infection-control procedures.
Test results may not be available in emergency settings, and HIV screening will fail to identify a newly infected person who has not yet developed antibodies that can be detected by the test, the guidelines said. In addition, other infectious agents may be present in a patient's blood, the document said.
"Therefore, regardless of whether or not HIV antibody testing is performed, universal precautions remain essential and must be followed in all cases for the protection of health care workers and patients," the guidelines said.
The CDC suggested that state and local health departments provide technical assistance and training to hospital staff responsible for HIV counseling and testing.
The recommendations are likely to be welcomed by some medical groups who resisted HIV-testing of health workers, arguing that health professionals were at greater risk of infection from their patients than their patients were of being infected by them.
There has only been one known instance in which a health care worker--a Florida dentist--has infected patients, while several dozen health care workers have been infected as a result of occupational exposure to patients.