Date Published: June 12, 2007
Publisher: Public Library of Science
Author(s): David R Holtgrave, Ronald Valdiserri
Abstract: BackgroundThe United States Centers for Disease Control and Prevention (CDC) recently recommended opt-out HIV testing (testing without the need for risk assessment and counseling) in all health care encounters in the US for persons 13–64 years old. However, the overall costs and consequences of these recommendations have not been estimated before. In this paper, I estimate the costs and public health impact of opt-out HIV testing relative to testing accompanied by client-centered counseling, and relative to a more targeted counseling and testing strategy.Methods and FindingsBasic methods of scenario and cost-effectiveness analysis were used, from a payer’s perspective over a one-year time horizon. I found that for the same programmatic cost of US$864,207,288, targeted counseling and testing services (at a 1% HIV seropositivity rate) would be preferred to opt-out testing: targeted services would newly diagnose more HIV infections (188,170 versus 56,940), prevent more HIV infections (14,553 versus 3,644), and do so at a lower gross cost per infection averted (US$59,383 versus US$237,149). While the study is limited by uncertainty in some input parameter values, the findings were robust across a variety of assumptions about these parameter values (including the estimated HIV seropositivity rate in the targeted counseling and testing scenario).ConclusionsWhile opt-out testing may be able to newly diagnose over 56,000 persons living with HIV in one year, abandoning client-centered counseling has real public health consequences in terms of HIV infections that could have been averted. Further, my analyses indicate that even when HIV seropositivity rates are as low as 0.3%, targeted counseling and testing performs better than opt-out testing on several key outcome variables. These analytic findings should be kept in mind as HIV counseling and testing policies are debated in the US.
Partial Text: In September 2006, the US Centers for Disease Control and Prevention (CDC) recommended that routine opt-out HIV testing (testing without the need for risk assessment and counseling) be offered in all health care settings in the nation (including substance use treatment settings, correctional health care facilities, emergency and urgent care clinics, primary care settings, and all public health and community health care clinics) . Such testing is to be offered to all 13- to 64-year-old persons in health care. Routine opt-out testing may eventually be discontinued in locales where HIV seroprevalence is documented at less than 0.1%. CDC acknowledged that some time-consuming aspects of HIV counseling and testing would need to be removed in order to make routine testing a reality in busy clinical settings. Consent to HIV testing would now accrue from general medical consent, not from specific written consent for the HIV test itself. No risk assessment or pretest counseling would be required. Post-test counseling may be offered for HIV-seronegative persons at high behavioral risk so long as the counseling does not become a barrier to routine testing. For persons who test HIV seropositive, linkages are to be provided to care, treatment, and prevention services, but scant detail is provided by CDC as to how this is to be achieved.
Standard methods of scenario and cost-effectiveness analysis were used to analyze the costs and consequences of the four cases listed above. The analyses employed a payer’s perspective [16,17] rather than a societal perspective so as to best estimate the resources needed to implement CDC’s recommendations. All costs are expressed in 2005 US dollars, and all analyses were done in Microsoft Excel 2003 (http://office.microsoft.com); see Table S1 under Supporting Information for the spreadsheet containing all formulae used here. A one-year time horizon was employed so as to examine intensively the initial impact of CDC’s recommendations and the alternative scenarios. (In the Discussion section, the results are interpreted for the reader interested in a societal perspective and a multiyear time horizon.)
Table 2 displays the results of the Basic Case Analysis (Opt-Out Testing), the Behavioral Offset Case Analysis, the Routine Counseling and Testing Case Analysis, and the Targeted Counseling and Testing Case Analysis. (Table S1 provides supplementary information on the spreadsheet used to conduct the analyses.) In the Basic Case, CDC’s recommended program of opt-out testing could be expected to test 65.5 million persons, newly identify HIV infection in 56,940 out of a total of 250,000 persons in the US unaware that they are living with HIV, and avert 3,644 (out of 40,000) HIV transmissions in one year at a programmatic cost of US$864.2 million (compared to CDC’s annual HIV prevention budget of a bit over US$700 million per year ). The cost per HIV infection averted is US$237,149. In one year, public support in the amount of US$961.3 million would be needed to provide care for persons newly diagnosed with HIV who are on public assistance or uninsured.
These analyses estimate that CDC’s recommended program of routine opt-out HIV testing might reach 22.8% of the 250,000 persons in the US now unaware that they are living with HIV. The program might prevent 9.1% of the 40,000 HIV infections that now occur annually in the US; if there is behavioral offset (i.e., increases in risk behavior due to lack of counseling), this percentage drops to 7.7%. Routine counseling and testing would cost substantially more to implement than opt-out testing, but would avert 13.3% of incident HIV infections in the US; considering both the additional costs and benefits, it is estimated that the cost per infection averted is roughly the same when comparing routine counseling and testing to either “testing-only” strategy.