If you're over 18 and a resident of the Bronx, the city of New York wants you to get tested for HIV sooner rather than later. The borough's death rate from AIDS is nearly 10 times the national average, which health officials attribute to the fact that about 25% of its residents only learn they are infected after the disease has progressed to full-blown AIDS. In an ambitious plan announced at the end of June, the New York City Department of Health hopes to make HIV testing a basic part of routine medical care as standard as mammograms, cholesterol screenings and setting broken arms. "Wherever you encounter the health care system, if you're offered the HIV test as part of the routine, then many more people are likely to do it," explains Dr. Monica Sweeney, the Dept. of Health's assistant commissioner for HIV prevention and control. But in the South Bronx, a blighted part of this borough just north of Manhattan, the initiative is encountering resistance from some of the very people who have devoted their careers to fighting the disease and comforting the afflicted.
Testing for HIV "is more than just drawing the blood or taking the swab," says Carmen Davila, community education director at CitiWide Harm Reduction, a needle-exchange facility in the Bronx where about 80% of patients are HIV-positive. "You also need to rub someone's back and talk to them. When I do testing, it's like a therapy session." Davila and others at CitiWide worry the initiative's approach ignores important parts of the treatment process including pre- and post-test counseling and reduces the delicate, often traumatic process of coping with a diagnosis to the emotional equivalent of a visit to the DMV. Having spent years educating the public about the disease, some HIV specialists don't trust general medical professionals to handle patients with respect and dignity. "The quality of medical services in the Bronx leaves a lot to be desired to begin with," says CitiWide executive director Ric Meyer. "To be talking about accelerating people through this raises a whole lot more questions than it answers."
If it works, the Bronx initiative could serve as a blueprint for how the nation's health care community tackles HIV/AIDS and save thousands of lives in the process. The Centers for Disease Control advocated routine widespread testing in 2003 and again in 2006, but so far it hasn't paid dividends. Washington, D.C., attempted to test 450,000 residents in 2006, but the initiative was a flop, reportedly meeting only about 10% of that target. New York's prospects for success may be brighter, partly because New York's health commissioner, Dr. Thomas Frieden, is one of the most effective in the country: under Mayor Michael Bloomberg, Frieden has successfully implemented citywide bans on smoking in bars and restaurants and artificial trans fats, and recently got a city law passed to force fast food restaurants to display calorie counts on menus.
In fighting HIV, the new plan, which encourages but does not require testing, changes some of the accepted rules. New York state law requires that patients be counseled about HIV before they give consent for a test, a process that typically takes about 20 minutes. The Bronx plan will whittle that process down to five minutes or less in many emergency rooms; studies have shown reducing consent barriers can dramatically increase testing rates. "We can remove a hurdle that doesn't really serve a purpose anymore," says Dr. Donna Futterman, an AIDS specialist at Montefiore Medical Center in the Bronx and one of the initiative's architects. But CitiWide's Meyer and others say those barriers are there for a reason: they ensure that counseling, testing and treatment are comprehensive and humane. "I'm absolutely on board with testing," he says. "But I have real questions about how this is going to work." Adds Carolina Lopez, executive director of New York Harm Reduction Educators: "The whole point of testing is prevention and the counseling piece is what provides people with the tools."
Beyond those concerns, Meyer, who says he learned of the plan just hours before it was announced, seems stung by the Department of Health's parachuting into his trench. "This was presented to us fait accompli," he says. "It was a slap in the face." He also suspects Bronx residents will bristle at the selection of their borough as the first mass-testing site. "There's still a tremendous amount of distrust in minority communities about people from outside coming in and saying, 'This is what's best for you,'" he says. Still, some 50 community-based organizations in the Bronx have signed up to be "initiative partners," and the city says it launched its campaign at the urging of Bronx community groups. Futterman believes that much of the squabbling over the plan is territorial. "AIDS is very politicized," she says. "A lot of people working in HIV/AIDS think they're the only ones who are smart enough to deal with it." Her message for the HIV/AIDS advocacy community: "Don't hold this thing hostage."
What's not in dispute is that too many Bronx residents are succumbing to AIDS. In part, that's because they're not aware they have it. City officials say about 250,000 out of the Bronx's 850,000 adult residents have never been tested. Manhattan's rate of AIDS infection 82 per 100,000, to the Bronx's 75 is the highest among the city's five boroughs, but the Bronx has the highest fatality rate from the disease. "That's a damning indictment of our system," Frieden told TIME. "We're failing to get people tested during the time that they are without symptoms and during the time when they may be infecting other people." The city has high hopes the testing plan will help stem that tide. But it'll have better luck if it can wrangle full support from community groups like CitiWide, whose deep roots in the borough provide access to the at-risk population the plan hopes to reach. Its supporters are hopeful, but realistic. "Changing paradigms is hard," Futterman says, "and this is a paradigm shift."
With reporting by Alyssa Fetini