Comment on AN20-Proposed Rule-Marie Crispin Anderson

I have 19 years experience in HIV nursing and HIV test counseling - specifically I have been a certified AIDS Care Registered Nurse for 14 years serving as local state president and on committees of the national Association of Nurses in AIDS Care including the committee on clinical issues. I have been clinical faculty in public health nursing at a large university school of nursing (concentration on HIV testing and HIV public education) for 5 of the 19 years, faculty in the school of medicine at a large university medical center, certified Red Cross instructor in HIV education including test counseling, and faculty with the local AIDS Education and Training Center for over 5 years. For the past 6 years I have been the facility HIV pretest and post test HIV counselor in a large VA Medical Center (including testing source patient veterans during employee exposure workups). At the VA I have personally tested over 3000 veterans for HIV which includes the required procedural test counseling and obtaining of signed informed consent. I have presented around 100 classes on HIV and HIV testing to veterans in our facility chemical recovery program. Having studied and considered the proposed VHA Directive 2009-XXX “Testing for Human Immunodeficiency Virus in Veterans Health Administration Facilities” I would like to offer my experienced and heart-felt opinion. I have reflected several weeks and now give my opinion which I believe is the same opinion of the majority of veterans I have counseled and taught over the past 6 years. First I do understand and respect federal law, public health law, and VA procedures and the rationale behind those procedures. I have executed the HIV testing procedure willingly, wholeheartedly, compassionately and expertly during the past 6 years. But the VA should be informed that the majority of veterans express that HIV testing procedures are – confusing and surprising: “You mean they haven’t tested me for HIV? Are you sure? Just look on my chart." The majority of veterans state the HIV counseling and signature procedure is not necessary and not desired. The majority of veterans believe the VA must have already tested them for HIV and they must have tested negative as no one ever told them otherwise. They expect that the VA has checked their blood during all those times their blood was drawn for anything that commonly might hurt their health (including HIV). They do not understand why the VA would so vigorously and excellently exam them for commonly known diseases and not include something as significant, epidemic, and devastating to them and their loved ones as HIV. This statement of bewilderment has occurred so routinely that several years ago I began asking veterans routinely at the onset of test counseling if they ever had a HIV test at the VA? The majority answer "yes", or "I think so" – because “you all are really good at checking for everything”. They expected the VA had already tested them for HIV. Upon review very few of these veterans had a HIV test result documented on their VA medical record. Therefore my personal opinion rests with the expectation of the majority of veterans – go ahead and just test them for HIV without required pretest procedures of any type. I would do so at a frequency suggested by the CDC minimally without any other regulations to stall or inhibit providers from ordering the test or to confuse or frustrate the veterans expecting the test. I think most providers would mention that the tests they are ordering include a HIV test just like they mention screening for cancer – it would be a part of professional and ethical expectations. The veterans in my regular HIV class often conclude that this virus is like an intelligent enemy – a worldwide terrorist – patiently waiting to render its worst effect. Covertly it hunkers down and checks off its daily work roster “Stall the humans one more day”. I think the great majority of veterans expect the VA to do what a decisive general would do - let the front line soldiers do what they are trained to do - and step to the forefront in this battle. I have seen my HIV Class on regular occasions clap and voice agreement heartily as they come to this conclusion - HIV needs to be hunted agressively. I used to teach my public health nursing students a general rule of thumb that they could easily remember: “The needs of the many outweigh the needs of the few”. I think in the case of HIV testing in the VA - the needs or expectations of the majority of veterans during a significant worldwide epidemic outweigh the needs or expectations of the few.