Public Policy Statement on HIV Testing of Patients in Addiction Treatment Facilities
Technology is currently available to assess the presence of HIV antibodies as well as to detect the presence of viral particles (antigens) in the human blood stream. The primary method for testing for antibodies is the ELISA test. Samples that react to the ELISA test are then tested with a more sophisticated blood test called the Western Blot, which confirms the presence of antibodies to HIV. There is a substantial incidence of false positive ELISA tests; therefore it is essential to confirm any positive ELISA with a Western Blot test. HIV antibodies usually appear within six (6) weeks of infection and are most always present by six (6) months post infection.
Antigens usually appear within a few weeks of infection and disappear within a few months. Later, if the virus is activated, the dormancy ends and the antigen level rises. A rising antigen level is typically associated with deterioration of a person's physical condition and may herald the development of AIDS in a person who had been previously asymptomatic. Antigen testing is not yet routinely available and is still being standardized for interpretation.
It is beneficial for all addiction treatment patients to know their HIV status, in order to facilitate treatment and to prevent transmission. Until testing is accomplished, it is safest to assume that all patients at-risk may have been infected; it is recommended that these patients refrain from donating blood, sperm, and organs, always practice safer sex, and boost their health and nutritional status through proper exercise and diet (a form of "universal precautions").
It is important to confirm the presence of HIV antibodies and presumed HIV infection by taking an antibody test as soon as it is safe and feasible. The appropriate time of HIV testing is still a difficult decision and should be individualized. In the drug and alcohol treatment setting, the rationale for deferral of testing is often based on a system's inability to respond effectively to patients' needs if they are tested. Practitioners and programs need to find their own balance between the positives and negatives of early testing of individuals within the patient population.
Since there are early treatment interventions possible, there has been a shift toward earlier detection of HIV infection. However, there are risks to HIV testing, especially with inadequate preparation for such testing. Assessments should focus special attention on patients who are not stable in treatment, many of whom are at risk for relapsing to drug use or becoming suicidal after being diagnosed as HIV positive.
Optimal treatment for any person with any illness would dictate thorough assessment, diagnosis and compilation of a medical record that included the assessment and diagnostic workup. When it comes to considering assessment, diagnostic testing and documentation of information regarding HIV illness, certain other considerations must be made. People who are HIV positive are subject to many forms of discrimination with respect to housing, job, child custody, and insurance benefits. Therefore the assessment, diagnosis and documentation process for information about HIV ought to be carefully considered and formalized in hospital and office policies and procedures. If confidentiality can be ensured, then it would be appropriate to order and document proper diagnostic procedures, specifically HIV antibody testing and results. If there is a question about the ability to ensure the confidentiality of this information, consideration ought to be given for alternatives, including off-site testing with no information in the medical record, on-site testing with no information in the medical record (information provided in a separate unnamed and confidential record, or testing without entering obvious information into the medical record about HIV infection (e.g., "test results positive" rather than "HIV antibody result positive"). Each of the latter two procedures requires specific mechanisms to institute and ensure compliance.
If a facility enters information routinely in the medical record, it might be appropriate and beneficial to meet with the patient, explain the possible implications of charting such information, and have the patient sign a consent form. Obviously, all of these activities ought to be done when the patient is cognitively intact and able to understand the significance of such decisions, rather than during the detox period when under the influence of or withdrawing from mood-altering drugs.
Handling this information in the patient community presents similar complex questions since disclosure of HIV status may not be met with support. Individualized decisions must be facilitated by knowledgeable staff in the treatment setting.
In light of the above, the American Society of Addiction Medicine recommends that:
1. It is generally helpful for individuals who may be HIV positive to know their HIV status.
2. ROUTINE TESTING is not recommended in addiction treatment settings; however, every patient who is at-risk or possible risk should be offered the opportunity to be tested for HIV. There should be no coercion to take the test as a condition of admission to a program or to treatment for addictions.
3. If testing is performed for addicted patients, consideration and timing of the testing should be individualized among physician, facility, and patient.
4. If testing is performed, adequate attention must be paid to informed consent, pretest counseling, post-test counseling, confidentiality and the potential impact of discovering HIV positive status while addicted or in addiction treatment.