Normalising HIV tests

It doesn’t seem long ago that testing a patient for HIV was a seriously big deal that could take half a doctor’s morning if you followed the rules to the letter.
Obligatory pre-test counselling had to cover everything from travel insurance to job discrimination, and results had to be delivered face-to-face regardless of the pre-test probability of a positive result.
From memory, a one-size-fits all approach was recommended which made little distinction between testing a regular at a gay sauna and a pimply adolescent after a furtive encounter with a classmate behind the home economics block.
As well, the specimen had to be anonymously labeled which meant dealing with multiple tubes and forms – when few of us had a computer – as rarely was an HIV test ordered in isolation.
The “special” status of HIV testing always seemed a bit odd to 6minutes, and perhaps politically motivated, given that tests for more immediately life-threatening illnesses came with no “special” regulations, and other potentially stigmatised illnesses with distressing implications , such as hepatitis B and C, were totally exempt from exceptional consideration.
Indeed, the years have seen the "special" rules about HIV testing watered down as sense has prevailed.
But even so, we were surprised by a Lancet comment piece, which alerted us to new CDC guidelines that recommend routine opt-out HIV testing in all health-care settings in patients aged 13-64.
Prevention counselling is not required under the guidelines, and negative results may be conveyed without direct contact between doctor and patient.
Strategically, the guidelines make public health sense in the US where it’s estimated around one-quarter of HIV-positive people are unaware they’re infected.
Even so, write The Lancet editorialists, public health benefits must be weighed against risks.
With an opt-out system in a busy clinic in areas with low literacy, there is “the danger that testing could become so customary and habitual that patients do not realise they can decline”, they write.
Moreover, will the move be a disincentive for primary health-care workers to provide risk-reduction counselling or gather information that can identify higher-risk individuals who require more frequent testing?
And what provisions are in place to help a 13 year old to cope with a diagnosis of HIV?
While the trend to normalising HIV tests is healthy, there's probably a middle ground, and these question must be answered.
In Australia, our record on HIV control has been so good, especially among intravenous drug-users, that it's a debate we hopefully wont have to have.