AEGiS-AIDSWeekly: HIV/AIDS: Controversial US strategy on HIV testing; ethnic disparities in diabetes care persist

Important note: Information in this article was accurate in June 2007. The state of the art may have changed since the publication date.

HIV/AIDS: Controversial US strategy on HIV testing; ethnic disparities in diabetes care persist

AIDSWEEKLY Plus; Monday, June 25, 2007
Staff Medical Writers

NewsRx -- The US Centers for Disease Control and Prevention (CDC) recently advised health professionals to offer every patient aged 13-64 years “opt-out” HIV testing (i.e. testing without the need for risk assessment and counseling). But a new study by Professor David Holtgrave (Johns Hopkins Bloomberg School of Public Health) in this week’s PLoS Medicine finds that testing only those people at high risk of HIV, rather than offering everybody a test, would be a better strategy for diagnosing HIV infections and for helping to stop the spread of the virus.

About a quarter of a million people in the US do not realize they are infected with HIV. Because they are unaware of their infection, they don’t get the medicines they need to stay healthy, and they may also be transmitting HIV to others unwittingly. The CDC hopes that its new recommendations on opt-out testing will allow health professionals to reach more of these people.

In order to assess the potential costs and public health impact of the CDC recommendations, Professor Holtgrave used two standard research techniques (cost effectiveness analysis and scenario analysis) to compare opt-out testing with “targeted counseling and testing.” In targeted testing, health professionals focus their efforts on those who are at increased risk of being HIV positive (e.g. patients attending sexual health clinics, drug treatment centers, or clinics in prisons). Such patients are offered counseling before the test, to assess their actual risk of HIV and to discuss what would happen in the event that the HIV test comes back positive. During counseling, people are also given advice on steps they can take to stay HIV negative if their test comes back negative, and to prevent infecting others if their test comes back positive.

According to Professor Holtgrave’s analysis, opt-out testing might reach 23% of those people who are currently unaware that they are HIV positive.The program might also prevent 9% of the 40,000 new HIV infections that occur each year in the US. The cost of averting one new infection would be US$237,149. In contrast, targeted counseling and testing might identify about 75% of people in the US now unaware they are living with HIV infection, and prevent about 36% of the new HIV infections. The cost of averting one new infection would be US$59,383.

Even when the author changed several assumptions in his analysis (e.g., assumptions about levels of HIV infection or the effectiveness of counseling), he found that targeted counseling and testing still performed better (so the results are ‘‘robust’’ across a variety of such assumptions).

The author concludes that “abandoning client-centered counseling has real public health consequences in terms of HIV infections that could have been averted.”

A related Perspective article that discusses Professor Holtgrave’s study is Late HIV Diagnosis: Bad Medicine and Worse Public Health.

Keywords: HIV/AIDS, AIDS, Acquired Immunodeficiency Syndrome, HIV, Human Immunodeficiency Virus, Public Health, Virology, U.S. Centers for Disease Control and Prevention.

This article was prepared by AIDS Weekly editors from staff and other reports.

Reference

Holtgrave DR, Costs and Consequences of the US Centers for Disease Control and Prevention's Recommendations for Opt-Out HIV Testing, PLoS Med. 2007 Jun 12;4(6):e194.

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