HIV This Week

Holtgrave DR. Costs and consequences of the US Centers for Disease Control and Prevention's recommendations for opt-out HIV testing. PLoS Med 2007 4:e194.

The United States Centers for Disease Control and Prevention (CDC) recently recommended opt-out HIV testing (testing without the need for risk assessment and counselling) in all health care encounters in the United States (US) for persons 13-64 years old. However, the overall costs and consequences of these recommendations have not been estimated before. In this paper, Holtgrave estimates the costs and public health impact of opt-out HIV testing relative to testing accompanied by client-centred counselling, and relative to a more targeted counselling and testing strategy. Basic methods of scenario and cost-effectiveness analysis were used, from a payer's perspective over a one-year time horizon. The author found that for the same programmatic cost of US$864,207,288, targeted counselling 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 counselling and testing scenario). While opt-out testing may be able to newly diagnose over 56,000 persons living with HIV in one year, abandoning client-centred counselling has real public health consequences in terms of HIV infections that could have been averted. Further, Holtgrave’s analyses indicate that even when HIV seropositivity rates are as low as 0.3%, targeted counselling and testing performs better than opt-out testing on several key outcome variables. These analytic findings should be kept in mind as HIV counselling and testing policies are debated in the US.

Editors’ note: This is the kind of analysis that should have underpinned the policy decision by CDC to change its recommendations on HIV testing. It underscores not only that opt-out testing without counselling misses an important opportunity for opening a dialogue about HIV prevention, but that it is more costly and has less public health impact than targeted client-centred counselling and testing in concentrated epidemics. A different conclusion would likely be reached if the cost-effectiveness analysis focused on non-targeted offering of HIV testing and counselling to all patients in resource-limited settings experiencing substantially higher HIV prevalence.

Cockcroft A, Andersson N, Milne D, Mokoena T, Masisi M. Community views about routine HIV testing and antiretroviral treatment in Botswana: signs of progress from a cross sectional study. BMC Int Health Hum Rights 2007;87:5.

The Botswana government began providing free antiretroviral therapy (ART) in 2002 and in 2004 introduced routine HIV testing (RHT) in government health facilities, aiming to increase HIV testing and uptake of ART. There have been concerns that the RHT programme might be coercive, lead to increased partner violence, and drive people away from government health services. Cockcroft and colleagues conducted a household survey of 1536 people in a stratified random sample of communities across Botswana, asking about use and experience of government health services, views about routine HIV testing, views about ART, and testing for HIV in the last 12 months. Focus groups further discussed issues about ART. Some 81% of respondents had visited a government clinic within the last 24 months. Of these 92% were satisfied with the service, 96% felt they were treated with respect and 90% were comfortable about confidentiality. Almost all respondents said they would choose a government clinic for treatment of AIDS. Nearly one half (47%) thought they were at risk of HIV. Those who had experienced partner violence within the last 12 months were more likely to think themselves at risk. One half of those who had visited a government facility in the last 24 months were offered HIV tests, and nearly half were tested. A few (8%) of those who were not asked thought they were tested. Most people (79%) had heard of routine HIV testing and 94% were in favour of it. Over one half (55%) of the entire sample had been tested for HIV within the last 12 months, one half of these through RHT. Women were more likely to have been tested. Nearly everyone (94%) had heard of ART and thought it could help AIDS. Focus groups identified problems of access to ART due to distance from treatment centres and long queues in the centres. Public awareness and approval of RHT was very high. The high rate of RHT has contributed to the overall high rate of HIV testing. The government's programme to increase HIV testing and uptake of ART is apparently working well. However, turning the tide of the epidemic will also require further concerted efforts to reduce the rate of new HIV infections.

Editors’ note: It is important to clarify what is meant by the term ‘routine HIV testing’. In the Botswana context, it is clearly intended as a routine offer not a routine test since half of those offered the test decided not to take it up at the time it was offered. Botswana’s approach of offering testing in government health facilities has high community acceptance and has helped normalise knowledge of serostatus – an important step in reducing stigma and increasing the effectiveness of prevention for both those found positive and those found negative. It facilitates timely initiation of prophylaxis and treatment for opportunistic infections for people with HIV infection and antiretroviral treatment for those who need it if it can be made widely and conveniently available.