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On the heels of the recent publication of two large, well-designed modeling studies that showed routine HIV testing to be cost-effective under a variety of scenarios (see ACC March 2005, p. 23 ), a few newly published articles provide further impetus for making substantial changes to HIV counseling and testing protocols.
Currently the CDC and the IDSA recommend routine, rather than voluntary, HIV testing and counseling for hospitalized patients in areas where HIV prevalence is ≥1%, but it is unclear to what degree this approach has been implemented. To assess this 1%-prevalence screening threshold, Walensky and colleagues (the same research team involved in one of the aforementioned models), have published another cost-effectiveness analysis of routine screening, this time focusing on hospital inpatients. The researchers modeled variables for both HIV disease and for acceptance, effectiveness, and cost of routine testing. Assuming an undiagnosed HIV prevalence of 1%, routine testing increased quality-adjusted life years by 6.13 per 1000 people at a cost-effectiveness ratio of approximately $35,000 per QALY gained, which, as the authors note, compares quite favorably to the cost-effectiveness of routine screening programs for other chronic conditions (e.g., diabetes, hypertension, and colon cancer). At an undiagnosed HIV prevalence of only 0.1%, routine screening remained cost-effective at approximately $65,000 per QALY gained.
"Routine testing is cost-effective because of HIV's unusually long preclinical phase, which can be diagnosed using very effective, comparatively inexpensive tests," study author David Paltiel told ACC . "Such testing, however, made no clinical or economic sense before the advent of potent antiretroviral therapy."
In a separate editorial, Beckwith and colleagues strongly endorse routine HIV testing in the U.S., regardless of the patient's perceived risk status or the local HIV prevalence. Medicare and Medicaid programs need to cover the costs of such screening, the authors urge. "Lack of awareness of one's serostatus is the primary obstacle to entry into care and access to therapy," according to Carlos del Rio, one of the editorial's authors and an Associate Editor of ACC . He points to data presented at the recent Retrovirus Conference from the NHANES III cohort, in which fully a third of HIV-infected people had CD4 counts <200 cells/mm, and only 20% of these highly immunocompromised individuals reported receiving antiretroviral therapy in the past month. However, 91% of all patients in the cohort who knew that they were HIV-positive were on a potent combination regimen. For del Rio, these data indicate the degree to which identifying those who are infected remains a tremendous obstacle to linking HIV-positive individuals with care and treatment. A recent editorial in the BMJ endorses a similar move from voluntary counseling and testing to routine testing in the U.K.
Although support for routine testing appears to be strong in the medical community, it is not universal. Some have expressed concern about the inevitable increase in false-positive results as testing becomes routine in low-prevalence populations. Routine testing might also raise concern among HIV activists, patient advocates, and the legal community. "We oppose routine' testing if it means mandatory' rather than voluntary' testing," according to Bennet Klein, AIDS Law Project Director for Gay and Lesbian Advocates and Defenders (GLAD), in Boston. Klein expressed concern that even a carefully constructed opt-out approach to routine testing might contravene important statutes in several states that guarantee patient consent for HIV tests. "There remains stigma attached to HIV," Klein concludes, "and any testing policy that undermines patient consent might have the effect of scaring people away from both HIV testing and routine medical care."
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