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NYC DOH Responds to New HIV Law Controversy
HIV Law Debate
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Newyorkblade.com
New Q&A with NYC Health Dept.
By KERRY ELEVELD
Monday, April 03, 2006
Editors note: Last week in Harlem the New York City Department of Health held the second of four community forums scheduled to discuss proposed changes in the state law on HIV testing, reporting and confidentiality. The following is an interview with Dr. Scott E. Kellerman, Assistant Commissioner for HIV/AIDS Services, about some of the proposals and issues being discussed at the forums.
Is the draft legislation that's circulating now a working document?
Over the past several months, we've been thinking about what we need to do. We have tens of thousands of people who need help; we're still missing about 30,000 people in this city alone. We've been talking to folks in the community and folks have been saying, "We can't really comment about what you're talking about and so you've got to put something out on paper." And that was exactly what we did, and that was released Monday [March 20th] and there was ensuing outcry. This is a part of the process. Now that people have something to react to, we want to hear what the community says. We want to hear what the folks in Albany say, we want to hear what our colleagues and peers say, and we're taking all that in. That's the purpose of the community forums.
One of the major concerns is how the Department of Health would implement a system where you locate people who have tested positive and offer them care. Can you discuss the current partner notification program Dr. Frieden mentioned at the forum in Harlem?
I think what the commissioner was talking is the extent to which other areas of the Health Department actually reach out to different populations for different reasons. One of those reasons is with respect to counseling partners and referrals. If someone were to go in and get diagnosed in one of our STD clinics for say, gonorrhea or syphilis, there are long-standing programs whereby it's discussed with that person that this is a communicable disease, and it's important for the people they've been with to be tested, and that the personnel in the STD clinics are happy to do that. The personnel who do this, the people in the STD clinics who we have doing partner counseling referrals for STDs-gonorrhea, syphilis, and for HIV-have extraordinary skills. They're linguistically appropriate, culturally appropriate and culturally competent. They know how to put people at ease and they know how to contact the folks. The health department has a long history of reaching out to folks, this is what the health department does, this is part of our repertoire.
Is there any reason to believe that it would be different if you were trying to link HIV positive people to care?
I believe that a lot of folks would welcome a hand. I think that no one really wants to get sicker and sicker. Sometimes life gets in the way, and folks might just need a helping hand to get back into treatment if they've dropped out.
Do you believe that the HIV test itself is stigmatizing?
The test itself isn't stigmatizing. But we're thinking that we need to increase the opportunity for people to get tested in medical settings. Right now, usually that offer of a test is based on a risk assessment. So the provider kind of looks at the person and decides whether they belong to a high-risk group, and there is actually a fair amount of literature out there that suggests that, in and of itself, is stigmatizing. People wonder, "Why did the doctor decide to ask me for an HIV test?" That actually has been documented in a variety of studies over the years. The CDC (Centers for Disease Control and Prevention) believes it. We believe it too. We think that in a place like a hospital, that if a doctor decides this person is going to be tested but that person is not, that in of itself is relatively stigmatizing.
Dr. Frieden mentioned that you're working on a new release dealing with stigma-can you talk about that?
We've had lots and lots of talks about this internally. We understand what a strong disincentive stigma can be toward getting into care, getting tested, taking care of oneself, especially with respect to HIV because it is such a stigmatizing disease. So we are very, very interested in doing something. We are in the process of doing our Center for Disease Control prevention portfolio where we're going to do the RFP (request for proposals) and that's going to be coming out, probably within the next month or two. We have CDC money, we have Ryan White [Care Act] money, for each of those funding streams, we put out these RFPs periodically, usually every year. So we're in the process of putting together the CDC prevention RFP, of which stigma, or I should say anti-stigma, will be a part.
Have major shifts in HIV reporting have taken place in the past?
In 1999-2000, the New York State and New York City health departments switched over to name-based HIV reporting. Prior to that, HIV was not reported by name-AIDS was, but AIDS is the end result of HIV. So back in the '80s and '90s, you got a really skewed idea of the actual problems of HIV and AIDS in New York City. You were only able to literally count the AIDS cases, you were not able to count the HIV cases. But since 2000, we were able to collect that information.
Was that a controversial change at the time?
I was at the CDC at that time. Yes, and it wasn't just New York City, because those laws pertaining to surveillance and what can be recorded by name and what can't be-those all vary from state to state. And so working at the CDC on HIV, I saw different states go through this in a variety of different ways. And for some places it was extraordinarily traumatic. In retrospect, the dire predictions that a lot of the folks locally said would happen, they simply haven't come true. I think that's a testament to the fact that people who work in HIV are passionately committed to making the surveillance programs work and making our treatment and prevention programs work.
How do you see written consent as a barrier to testing?
I'm a gay man and I know what my risks are. I know that I can go to GMHC or Housing Works or Harlem United or any of the places in town that offer wonderful counseling services. But for the 20,000 people that we think are walking around and are infected but unaware, they're not necessarily the ones who are going to be walking into GMHC looking for testing. But they may be going to an Emergency Room or to a doctor's office for medical care. So we think we might be able to increase the availability of testing or increase the offer of testing in those settings.
The unfortunate thing is, because of the way health care is these days, most doctors, most providers have very little time to spend. So they perceive having to stop the process of the one-on-one between the patient and the provider, get a separate piece of paper, and cover the 14 points that have been put forth in the law over the years for pre-testing-that's a real barrier if you only have seven or 10 minutes with a patient. How do you make it so that providers can actually realistically offer the test in different settings besides the counseling and testing program at somewhere like GMHC or Harlem United? There's a study that shows that 60 percent of folks who are diagnosed in the previous year had been through a medical facility in that previous year. So if voluntary testing had been offered in that setting, perhaps they would have been diagnosed that much sooner. Not everybody goes to ERs, not everybody goes to the doctor, but a whole lot of people do; and if we can [offer] those folks the opportunity to be tested, then we're going to do them a service.
Are you working on anything to address those who don't go to the doctor, don't go to the ER and aren't likely to seek out testing at a community center?
I'm so glad that you've touched on this, because I'm really proud of the efforts that we've made over the last year here at the Health Department. There are lots of people who don't understand what the risk is; they would never go to a counseling and testing program. But then still, there are people who would never access medical care either, and homeless shelters is a great example of that.
Hopefully over the next month or two, we have plans to roll out testing so that virtually every single adult entering the homeless shelter system will be offered an HIV test, and that's citywide. So we're delighted about that.
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