In this study population, patients generally viewed the three 2006 CDC HIV testing methods (opt-out approach, general medical consent, and optional prevention counseling) as being as morally acceptable as the 2001 testing methods (opt-in approach, specific signed consent, and mandatory prevention counseling). In contrast, clinicians generally found the 2006 testing methods to be relatively more ethically concerning than did patients. Yet, their level of concern varied by testing method and was low for most concerns evaluated (e.g., the largest difference was 1.57 on a 0–4 point scale). In fact, although clinicians considered the opt-out approach and use of general medical consent as relatively more ethically troubling than did patients, they were more apt than patients to support the justifications cited in support of the opt-out approach and use of general medical consent and had a relatively greater preference for these two testing methods. Unlike their clinicians, patients indicated less support for the justifications made for the opt-out approach and use of the general medical consent, and had a relatively greater preference for optional prevention counseling. We did not assess the reasons for the divergent views between clinicians and patients, but the differences might be explained by clinicians' experience in using the 2001 HIV testing methods. Clinicians perhaps also hold more of a public health and health delivery view of HIV testing, while patients have a consumer's view. Alternatively, clinicians might have some knowledge of the debate over the 2006 CDC HIV testing methods in the medical literature. It is unclear if this divergence will decrease or become more pronounced as more clinicians implement and patients experience the 2006 testing methods firsthand.
It is interesting to observe that clinicians appear to have a more conservative perspective than patients regarding the ethical concerns raised about the 2006 recommendations, which bodes poorly for their planned implementation. The results show that CDC still must address ethical concerns about its 2006 -methods among clinicians who are being asked to implement them. The study results also indicate that, at least among this sample, patients are not yet persuaded by the ethical justifications offered for the 2006 HIV testing methods. If patients are not convinced about the merits of the recommended methods, and clinicians have ethical concerns about them, then the hope for their implementation might not be fully realized. As a consequence, the subsequent increase in HIV testing with resultant increase in linkage to care and reduction in HIV transmission might not occur. If clinicians do not think the methods are right for patients, despite their beliefs in how they might be justified, they might not employ them, even if patients do not have objections to them.
Our study was subject to a number of limitations. First, it did not address the legal or operational challenges to the 2006 CDC recommendations and did not determine if the 2006 CDC HIV testing methods are morally sound or troublesome. Second, the study was conducted in a state that had not yet enacted the 2006 CDC HIV testing recommendations, so experience with the 2006 HIV testing methods was likely limited. However, it is arguable that this state might be the ideal setting in which to assess the ethical concerns and justifications made for new public health policies. Third, because the study was conducted at academic institutions, it is unclear how well these findings can be generalized to non-academic institutions, as testing practices, clinician perspectives, patient demographic characteristics, and HIV prevalence might vary between these types of institutions. Furthermore, we cannot assess the viewpoints of the clinicians and patients who declined to participate or were ineligible for the study.
Fourth, it is possible that participants did not understand the ethical concerns or justifications examined in the study, despite cognitive-based assessments demonstrating patient comprehension of the concepts and questions, the ACASI format, and efforts to construct the survey to assess viewpoints rather than prior knowledge about the topics addressed. Regardless, any possible misunderstandings might account for some of the differences between clinicians and patients.