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STD Testing

I'd like to ask some questions/start a discussion about what level of STD testing is appropriate. Below the cut for those who want to skip, but I'd be interested in the opinions of those who are willing to share. Several discussions of STD risk lately have caused me to ponder what sort of testing I should do and what sort of testing I should ask current and potential partners to do. I'm interested in facts about what level of testing others are doing and opinions about what is appropriate. One of the big questions is how often do you want to do testing? Insurance seems to want to cover about once a year typically. Is that often enough? Given the incubation period for HIV, it seems like six months between testing might also be reasonable, but I'm not sure if it is worth getting testing that is not covered by insurance. I understand there are ways to get free/cheap testing. My experience has been that I get a lot less stressed having testing done by my normal doctor than say at MGH. How often do you test yourself? How often should partners get testing?

What tests are important to get? I'm interested both for males and females. Some things are obvious. I think the biggest question for me is Herpes testing; I've been getting mixed recommendations from doctors. My doctor seems to think it's important to get, although other quite knowledgeable and liberal doctors think that there are a lot of cases where it doesn't make sense to test for Herpes. What else should I be thinking about?

I'd be interested in any thoughts you'd be willing to share. I'd prefer comments not be anonymous, although I'll take what I can get. If people feel uncomfortable commenting on a public entry I can friends lock this. I'm as much interested in your reasoning as your answers to questions.

Comments

Once you're in the office, might as well test for everything. How often you go depends on how many partners you have. If the circle is truly closed, there's little need after a couple at the outset.
I'm not 100% sure that I agree with your first statement... Tests cost money and consume resources. So, even if you don't personally pay more (due to insurance coverage), unnecessary medical testing does increase medical spending and result in some costs to society as a whole.

I do agree with your second point, though...

Some people think that regular testing is important, even in a closed circle, because of the possibility that someone is having outside activities that they haven't disclosed. I'm not sure, though, why I would trust someone to be honest about the results of their STD tests, if I couldn't trust them to be honest about their outside activities.
If the circle is truly closed, there's little need after a couple at the outset.

The question then becomes how one can know whether the circle is truly closed. I once had a primary partner have an unprotected one-night-stand that I didn't find out about until a month after the fact. I think I'd have to be very close to *everyone* in the chain in order to actually believe that the circle was as closed as it is claimed to be.

I can't really imagine this being at all reliable beyond a tight (probably co-habiting) triad or quad.
The helpful folks at Planned Parenthood told me that if I want to schedule an HIV test, I should do it anonymously through them. Apparently some insurance companies will consider you "high-risk" if you specifically request an HIV test, and will jack up your rates accordingly.
When I got my HIV test done yesterday, my doctor's office offered me two choices for how my test could be handled from an insurance/billing perspective:

(1) I could pay myself, and no information would be fowarded to my insurance company at all.

(2) "Coded" information could be sent to my insurance company to bill them for the test. They didn't explicitly indicate what information would be coded in what way, they did indicate that my insurance company would not know that I had been given an HIV test...

Either way, the information that is sent to the lab is completely anonymous.


Sam already knows this, but I thought I'd post in an attempt to initiate some discussion...

I have a very good OB/GYN that I've been seeing for many years and with whom I feel that I can share anything. He is also a very well respected and progressive doctor who keeps up on advances in the field.

I would, personally, prefer to have all of my testing done by my doctor. If I had anonymous testing done that indicated that I had anything, or might have anything, the first thing that I would do is run to this doctor, anyway. So, I would rather that he choose the specific tests to be performed, that he choose the lab in which to have them performed, and that he interpret the results.

My doctor offers me personal advice based on my situation. I don't know how he would advise other people in other situations.

He seems to think that it is a good idea for me to be tested annually for both HIV and Syphillis, because both diseases can be spread for a significant period of time before they have any symptoms that would otherwise be detected by me or my doctor. In fact, he volunteered his opinion that everyone who has more than one partner should be tested regularly for both HIV and Syphillis, to cut down on the spread of these diseases.

He doesn't see much value in doing culture tests for Clymidia and Gonorrhea, unless symptoms are present during my cervical exam that indicate that there is an infection. Because of previous medical history, he does a close (microscopic) inspection of my cervix as part of my exam, so he would see an infection if one was present. I asked him to do these culture tests, anyway, because Sam and I had agreed to have them, but I am not sure if it makes sense to continue requesting them annually, because a microscopic exam seems adequate. Thoughts?

Herpes is more complicated... Last year, when I requested a full suite of STD tests, my doctor did a herpes test and the test was negative, indicating either that I've never had either type of herpes, or that my last outbreak of either type was so long ago that my antibody levels are no longer elevated. This is what I expected... I am not sure I would remember if I had cold sores near my mouth as a child, but I have never had genital sores.

BTW, one interesting discovery I made while looking into this topic... the small white sores that some people get inside of their mouths are not herpes-related cold sores (as I previously thought), they are non-herpes-related (and non-contagious) canker sores. Herpes sores occur outside the mouth around the lips, on the chin, etc. and are much larger and totally different. Apparently, this is a common medical misconception.

Some people seem to consider Herpes testing to be unnecessary, because it is not clear what you would do (other than inform others) if you had a positive test. Nor is it clear what others should do if they are informed that their partner has had a positive herpes test. There is a relatively new drug available (Valtrex), though, that not only prevents Herpes outbreaks but also prevents the spread of Herpes. So, if you were able to identify that you have genital Herpes, you might be able to take Valtrex to significantly reduce the chance of spreading it to your partners.

When we talked about testing this year, my doctor indicated that another Herpes test wasn't really necessary. He indicated that I would know if I had had a Herpes outbreak (of either kind, in either location) in the last year, and that if I had not had any noticeable and painful sores, I would get roughly the same results as last year. He did indicate that if I ever have any sores in the genital area, I should come in to his office right away, and he will do a culture test. He thinks that would be a more effective plan for identifying and preventing the spread of genital Herpes than doing an annual blood test. I did request the blood test, anyway, because Sam and I had agreed to have a Herpes test, but I'm not sure if I should continue to request this test annually, either. Thoughts?

I have been getting this testing annually, as part of my annual exam. My doctor hasn't suggested that I do more frequent testing, but I haven't specifically asked him about what the optimal frequency would be.










I'm a big fan of testing. It is really important to know if you're infected with something, so that you don't spread it to others (and so that, if it's something you can be treated for, you can get treatment as soon as possible).

However, if you are monogamous and your partner is monogamous, or if you are celibate (e.g. I am usually monogamous, but for the last few months I have been celibate) then I think getting tested once (not once a year, just once) is enough. I got tested once, I was clean (even for herpes, which I was particularly worried about because I've been getting mouth sores since I was a kid, but apparently they're caused by something else). That is reassurance that I am clean and my partner is clean (because if he weren't, then he probably would have spread something to me, but given that he's never had another sexual partner...)

As for getting tested more than once a year, if you're sexually active with more than one partner (or monogamous with someone who has more than one partner) isn't it a better idea to get tested once a year and not have sex with anyone who you don't trust and hasn't been tested recently?

As for herpes, don't forgo testing because there's nothing you can do about it. There are treatments for the symptoms, there are risks to pregnancy if a woman has it, and most importantly, you don't want to spread it around!
Related threads in my own journal:

"Safe sex":
http://elusiveat.livejournal.com/67805.html

"Safe sex II: herpes screening":
http://elusiveat.livejournal.com/79998.html

I think once every six months to a year is appropriate if you're in a poly relationship and using condoms.

Once every three months is recommended by some, but I think that's truly excessive, unless you have unprotected vaginal or anal intercourse (or similarly high-risk activities, such as sharing IV needles) with one or more promiscuous/high-risk partners. But I think that afforementioned activity is a really bad idea even if everyone gets tested once every three months.
I totally don't get the anonymous HIV testing thng. The claim that
your insurance rates will go up is bogus at least for people in group
insurance plans. It's possible that your group rates might go up
(although in this day and age I'd doubt that absent recent
statistics), but in a group as big as MIT's health plan, that's going
to be negligible. And if I do get positive results from anonymous
testing I'm damn well going to be camping out at my doctor's office
until I get an appointment. What am I missing.

I find your
comments kind of interesting on another front. You're recommending
what I would class as above-average frequency in testing from what I've seen. However your comments about understanding everything has a risk and balancing this is not something I typically see from people who recommend testing before every new partner.
I'm not at all saying you are wrong--just I find the combination interesting.

Some of this may vary from one state to another.

I'm under the impression that Massachusetts may limit insurance companies' ability to limit coverage of pre-existing conditions more than many other states.

If that's true, you might have trouble moving away from Massachusetts and keeping coverage if you end up with an expensive disease.

On the other hand, does non-anonymous testing mean that you can get a piece of paper from your doctor that has both your name and the actual test result printed on it that you can give to your partner, and does that give your partner more reliable information about your test results than with anonymous testing?

The other thing to note with group pools is that in Massachusetts, all employers with 50 or fewer employees (or maybe it's fewer than 50) are in the small group pool for a given plan; if you get sick in an expensive way, that cost gets distributed over all the companies with fewer than 50 people. And this summer, Massachusetts is merging the small group pool with the individual pool. So people in smaller companies still benefit from being in a huge pool.
There are two variants of the pre-existing condition argument. The
first is that if you do not have insurance today you may want
anonymous testing because if you have HIV you will not be able to get HIV treatment easily when you get insurance because of pre-existing condition clauses. That's true, although as best I can tell, hiding knowledge that you knew you had such a condition before getting insurance clearly classifies as insurance fraud. Now, as insurance fraud goes, that seems like one of the more morally defensible types of insurance fraud. It doesn't apply to me though; I already have insurance.


The other pre-existing condition argument is that if your insurance company finds you have HIV, it my be harder to change insurance companies or move states. Absolutely true. So, what's your plan? Are you planning on not treating your HIV infection? Or are you planning on paying treatment costs out of pocket so your insurance company does not find out? See, my plan was going to be to not get HIV in the first place. If that plan fails, though, I plan to get treated, and I plan to use medical insurance to pay whatever costs it will pay. Insurance companies find out when you get treatment for conditions and they pay for that treatment. So i don't see how this pre-existing condition argument applies either.

That sounds to me like insurance fraud that would probably be impossible to prove.

In Massachusetts, I think if you didn't sign up for health insurance until right after a hypothetical anonymous HIV+ result, you'd have to wait six months for the insurance to pay for outpatient treatment, which might ironically make you more sick and force the insurer to pay for inpatient care. Or something. I can't really believe that they would actually be that dumb, but maybe they are.

Your arguments have certainly made me think, because my intuition thinks you are probably right, but what you are arguing is so different than what I have heard anywhere else that I'm a little concerned that there might actually be some subtly that you and I are missing.

Another factor is that I hear that most of the general population is extremely sensitive to the possibility that they might have HIV in such a way that they're reluctant to get tested. Anonymous testing may be more comfortable for such people, I hear. I can't really relate to this firsthand.

I seem to recall someone (who I'm sure you know, but I think mentioning a name here would risk violating privacy) also ran into problems with billing after having non-anonymous tests, I think because his insurance refused to pay, unexpectedly, many years ago. I forget exactly why that was that they wouldn't pay. But anonymous testing may be financially preferable if your insurance won't cover testing.

My primary care doctor doesn't seem to be one who's especially comfortable talking about sexuality; and going to an anonymous STD testing clinic means that you will be talking to someone who specialises in STDs, and one could hope that that implies that they will be comfortable talking about sexuality to the extent that it's necessary to deal with people's conditions.
I started with anonymous HIV testing because I used to work at an HMO, and I had this vision of everyone and anyone at the HMO being able to tell that I had this test done. There was then, and probably still is now, a stigma just on having the test done - after all, if only people who have been doing Bad Things will become HIV positive, then why would anyone get the test unless that person had been doing Bad Things?

I then started getting tested at my doctor's office because I could only track down one clinic that would do anonymous testing for cheap (As I recall, MGH was "by donation" back then) and money was tight. And anyway, MGH only had evening hours once per week and it was hard for me to get there before they closed.

My doctor is hesitant to test, though. I have never asked why, but a friend goes to the same doctor explained it to me once. I don't remember the details of her explanation, but the impression she got was that the doctor was attempting to protect the patient from some danger, maybe the pre-existing condition thing, not sure. Not saying that my doctor won't test - just that the doctor sort of cringes each year when I request testing.

I'm not up on the latest tests, but I'm sure even recent ones have limits on... how do I say this... limits on how soon after an infection you can tell that you're infected. I don't even want to speculate on what those limits are nowadays, but I remember hearing years and years ago that an HIV test taken today couldn't tell you if you had contracted the virus yesterday, or a week ago...
It's my understanding that current HIV tests will show an infection within six months.
I'm not trying to accuse your doctor of anything, but some insurance plans heavily incentivize doctors to limit the costs incurred by their patients... My understand is that this is very direct -- for each patient that a PCP keeps below a specified medical expense level, they get a financial bonus.

So, in some cases, our doctors may have a financial incentive to discourage us from getting tested.

If someone has been sexually active for many years, a test that might miss things from the last six months still will give you a pretty good idea of whether they contracted HIV during the majority of the time they have been sexually active.

As of several years ago, I think the tests were almost perfectly reliable for anything contracted at least six months ago, and would sometimes detect an infection that had occured within the last three months, or perhaps even more recently.

I think with a doctor who cringes like that, I would probably be inclined to ask for an explaination, and if no good explaination is offered, think about looking for another doctor.