Friday, October 5, 2007

Routine HIV Tests, the Class' First Test, and the Blue Angels

So, I had my first doctor's visit since I got here today. Here's the front door and elevator bank. Nice building! Especially for a doctor who takes HMO insurance.
My new doctor (physician's assistant, actually) seems like a nice enough guy. Now that I've gotten my back pain under control, there really wasn't anything pressing to discuss, just getting a prescription for my anti-depressant medicine.

This will be the first time I get a 'routine' HIV test. I wouldn't have gotten one under normal circumstances, since there's no reason to be concerned (oh, and I wish there was!). But the CDC has come out with a new policy suggesting that everyone get an HIV test every once and a while on a routine basis.
After some initial hesitation, I have come around to strongly supporting that policy, so I would look a little hypocritical if I supported routine testing on the one hand, and didn't do it on the other.
In the late 1980's and 1990's, while I was active with ActUp/RI, we strongly opposed routine testing, mainly because it would be happening in doctor's offices, and we felt that that was one of the worst places to try to learn anything useful about HIV. Partly because most doctors at the time were extremely uninformed, but mostly because if you got a positive test, the results would be part of your medical record, which despite what it looks like is a very public set of documents for anyone with the slightest incliniation to find out more about you.
Having such a public record would also make you ineligible for health insurance at all. At the time, there was even a fairly widespread policy of denying any HIV-related care even for people with insurance, especially if they fit one of the 'classic' risk factors.
So we strongly advocated for people to get anonymous testing, at one of the specialized HIV testing sites, run either by the Health Department, or by a reputable non-profit agency.

I think that was definitely the right strategy at the time. But circumstances have changed. For one thing, it is not as devastating to learn that you have HIV these days. It's also not anywhere near as hard to find competent care. And also everyone, including doctors and the general public, has gotten much less paranoid and reactionary about people with HIV. And, although it is still legal, and common practice, to deny HIV+ individuals any health coverage at all, at least it is illegal to deny coverage to someone for HIV-related care once they are already insured. So at this point, it makes more sense to offer HIV testing as a routine part of care, while still maintaining the capacity to offer anonymous free HIV testing sites, especially for people who currently have no health insurance.

But here's the big difference in my shift in opinion. Selective testing for HIV just doesn't work. For the same reason that virtually every strategy designed to work only on a high risk population is inefficient, and often counter-productive.
In this case in particular, having a conversation about whether to get HIV testing used to be about having a sexual and drug use risk behaviors. Essentially, several hurdles that have very little to do with whether you should get an HIV test or not had to be surpassed - First, your doctor had to think you were "at risk", which is a strange way to think about someone you care about. Second, you yourself had to think (or be convinced) that you were "at risk". That's also not a fun state of mind to be in. That's probably why the best definition of "promiscuous" is "anyone who has more sex than me". Third, you had to set aside time in the doctor's visit to have that conversation. And these days, with 10 minute appointments, can you really afford to spend 5 talking about an issue that isn't on the top of your priority list?
The other thing that making a big deal out of HIV testing did was re-inforce the idea that having HIV was a dangerous thing, and makes you a bad person. After all, if only high risk people should be tested, that sets up the notion that the risk itself is essentially a disease.
With routine testing, the conversation about getting tested didn't make me defensive about whether I considered myself to be "at risk", that was a non-issue in the process.

Well, I gave my students the first mid-term on Tuesday, and my initial reaction on leafing through them was that it had been a bloodbath. Several hadn't put any answers down at all for large parts of the exam, and others had scribbled things that didn't make any sense at all. Only a handful really "got it". I was despondent the next day, because that meant that 1) I wasn't teaching well, 2) they just didn't prepare, and/or 3) the test was not fair, in that I didn't allow enough time to complete it. I had long chats with some of the important teachers in my life (Rachel, Dad, & Kate) about what to do. I think there's a degree of all three involved, so my strategy now is to cut back somewhat on the scope of the class to make sure we can get through everything, adjust the grading system so that if they bombed, they can learn from the error of not preparing, and recover without a significant "drag" from the first test, and to set up office hours. I've given them my email and cell phone, and encouraged them to call many times, but it hasn't worked. I'm hoping that having drop-in times will help people get over their hindrances about asking for help.

Anyway, a few days later, as I have begun grading them, I'm not nearly as pessimistic. There's a lot to be happy about in their performance, and a lot of the stuff that just looked like random scribblings before is starting to fall into place, there are aspects of it that I can give credit for, so I think they are going to do better overall than I initially thought. So, it's not necessarily even going to be a bad experience overall. But, I'm still going to implement those changes right away.

The Blue Angels were flying over the city today, which was very disconcerting. They were flying right on top of the buildings. Suddenly the sky would rip open, and you couldn't tell where it was coming from because everything was echoing off the buildings. I was downtown, and went home to see if I could head out to the Golden Gate Bridge, so I could at least see them. But by the time I got home, they were done, so no pictures, I'm afraid.

1 comment:

  1. A thought experiment... the strategy of "Let's get tested TOGETHER BEFORE we have sex, for A VARIETY of STDs." Sexual health checkups reduce ambiguity and can be like anything else POTENTIAL sex partners might do together.