CDC wants HIV tests for everyone

[mshheaddoc]

Link here


I think this is a good idea as 30% of those infected don't realize that they are yet. Also maybe being in preventive measures part of physicals then it would cover most people. But honestly, how many healthy young adults/middle-aged American's get a physical? Most I know don't unless they need it for their employment or the such. If its covered under ob/gyn annuals for females that is my only physical every year.

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[logos]

Hmm...my gut reaction is that this would be a bad idea. I'd like to see the (mathematical) justification for it. The test would have to have an exceedingly low false positive rate due to the very low prevelance of HIV for it to be worth doing (yey biostats class!).

I would guess the cost/false positives would outway the value, but i'd be very interested in seeing the numbers.

 

[mshheaddoc]

If they were using tests with minimal false positives then maybe that would eliviate. I would imagine it would be a blood test but you are right. Costs are going to go up.

 

[prana_md]

I work in an ED on a CDC project that offers rapid HIV testing to all ED patients. The article mentions that the CDC already recommends screening (ie, testing everyone) in "high risk" areas. Technically, a high risk area is anywhere where HIV prevalence exceeds 1%. The community that my ED is in is considered high risk. The specificity for the test we use is 99.8%. (Yup, sens and spec confuse me, too.) Anyone who tests positive gets a confirmatory Western blot blood test. Our tests cost about $10 each.

 

[McDoctor]

I'm glad they will be eliminating the requirement for pre-test counseling and consent. This seems to add to the stigma of getting tested for HIV, and seems to make patients uncomfortable. I think we will need to better familiarize ourselves regarding which diseases can create a false positive ELISA, with a Western Blot "indeterminate" which I have never seen happen but have been told does occur(?I think SLE can do this). This is something that I think would be encountered more if we started screening lower risk patients and an "indeterminate" result would cause alot of anxiety for the patient.

 

[prana_md]

I'm glad they will be eliminating the requirement for pre-test counseling and consent. This seems to add to the stigma of getting tested for HIV, and seems to make patients uncomfortable.

Yes! We've found that patients are very comfortable getting tested in a streamlined, matter-of-fact way. We still need counselors for the positives; I don't think I would ever argue against them ... they're awesome.

 

[colt]

I question how effective this would be.

First of all, it would be a big waste of money to test everyone when the heart of the disease lies in the gay-male/IDU population. I'd say target and educate the heart of the disease with all the money it cost to test everyone. Secondly, how can you be assured that those at risk or with the disease are going to come in for a physical every year? It seems logical that those who go for yearly physicals (or physicals at all) would also be less likely to have unprotected anal sex or use IDs.

I'd say just getting more people to come in for physicals would be a HUGE accomplishment. Forget HIV, just having a physical would potentialy uncover a slew of treatable diseases and conditions, which are more rampet than HIV.

 

[mshheaddoc]

Actually this would be a great way to get people in for physicals if it actually works. Yes the majority are GM/IDU but they need physicals too. Additionally since the highest new cases are in african americans and latinos and these two ethnicities are often part of the underserved populations especially in cities then maybe there should be a push for free clinics to offer free physicals.

With 30% of ALL individuals not knowing if they are HIV postive (Afr. Am. women are the 2nd highest number growing in population) this would be an excellent idea.

First get people to see their primary doctors for regular physicals to monitor common health problems. Oh and don't have a 3-6 month waiting list for physicals either. That irks me as well.

 

[Gut Shot]

First of all, it would be a big waste of money to test everyone when the heart of the disease lies in the gay-male/IDU population.

Maybe, maybe not.

Expanded screening for HIV in the United States--an analysis of cost-effectiveness.

Paltiel AD, Weinstein MC, Kimmel AD, Seage GR 3rd, Losina E, Zhang H, Freedberg KA, Walensky RP. N Engl J Med. 2005352:586-95, 2005.

BACKGROUND: Although the Centers for Disease Control and Prevention (CDC) recommend routine HIV counseling, testing, and referral (HIVCTR) in settings with at least a 1 percent prevalence of HIV, roughly 280,000 Americans are unaware of their human immunodeficiency virus (HIV) infection. The effect of expanded screening for HIV is unknown in the era of effective antiretroviral therapy.

METHODS: We developed a computer simulation model of HIV screening and treatment to compare routine, voluntary HIVCTR with current practice in three target populations: "high-risk" (3.0 percent prevalence of undiagnosed HIV infection; 1.2 percent annual incidence); "CDC threshold" (1.0 percent and 0.12 percent, respectively); and "U.S. general" (0.1 percent and 0.01 percent). Input data were derived from clinical trials and observational cohorts. Outcomes included quality-adjusted survival, cost, and cost-effectiveness.

RESULTS: In the high-risk population, the addition of one-time screening for HIV antibodies with an enzyme-linked immunosorbent assay (ELISA) to current practice was associated with earlier diagnosis of HIV (mean CD4 cell count at diagnosis, 210 vs. 154 per cubic millimeter). One-time screening also improved average survival time among HIV-infected patients (quality-adjusted survival, 220.7 months vs. 219.8 months). The incremental cost-effectiveness was 36,000 dollars per quality-adjusted life-year gained. Testing every five years cost 50,000 dollars per quality-adjusted life-year gained, and testing every three years cost 63,000 dollars per quality-adjusted life-year gained. In the CDC threshold population, the cost-effectiveness ratio for one-time screening with ELISA was 38,000 dollars per quality-adjusted life-year gained, whereas testing every five years cost 71,000 dollars per quality-adjusted life-year gained, and testing every three years cost 85,000 dollars per quality-adjusted life-year gained. In the U.S. general population, one-time screening cost 113,000 dollars per quality-adjusted life-year gained.

CONCLUSIONS: In all but the lowest-risk populations, routine, voluntary screening for HIV once every three to five years is justified on both clinical and cost-effectiveness grounds. One-time screening in the general population may also be cost-effective.

 

[trustwomen]

I think it's a good idea, but what's that bit about deporting people who test positive? It's not fair to make tests mandatory but then have all this legal fallout from a positive result...I'm supportive of the testing with the goal of informing more patients of their status and reducing the stigma of testing. Not as a social control mechanism or legal effort.

I am slightly concerned that it's a one-time thing - with HIV counseling, one of the biggest things you have to counter when giving a negative result is the patient saying "OK, great!!!" followed by a return to high-risk behaviour with the (newfound) firm conviction that they must be "immune or something", or that "anyway this was God confirming that it definitely won't happen to me".

 

[Vox Animo]

The government is just becoming more on more invasive on personal freedom.

In the midwest, central and southern illinois, aids cases are about 1:10,000. That does not do anything close to merit mandatory testing.

Let's not give up our privacy so easily.

 

[mshheaddoc]

Big generalization since I'm in Oklahoma and the amount of HIV patients in urban areas actually is quite high.

And what does this have to do with privacy? I don't see it being a privacy issue as only if you are tested positive is it reported to the CDC. HIPPA will protect.

 

[mshheaddoc]

Those who criticize CDC's suggestions ...

http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=37180

 

[logos]

Those who criticize CDC's suggestions ...

http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=37180

I think this is a very poor criticism. I dont see any reason to treat HIV as a special circumstance. While initially HIV was very scary and maybe warranted some special attention, we now know a lot more about it. I see no reason for a special consent for HIV testing or pre-test counciling. Do people having their cholesterol require these things.

While i question the wisdom of testing everyone, I dont question it for the same reason as this woman. I suspect instead that this is being pushed with the idea that we will "find" these mysterious 250K people who have asymptomatic HIV and dont know it. While that is a noble goal, I question whether or not it is atainable at a reasonable cost in terms of both money and scaring people with false positives. Thats why i'd be interested in an explaination of the numbers. As far as i'm concerned, if the stats show that it would be beneficial, at a reasonable cost for that benefit, then lets do it.

 

[Hopeful_Doc]

I would say that most people who have HIV and dont know it, also do not have regular physicals or doctors visits.

good idea on paper, bad in practical use.

 

[Gut Shot]

That does not do anything close to merit mandatory testing.

Patients would be able to decline being tested, therefore it is not mandatory.

In contrast to your insinuation, the proposal does not involve dragging people from their homes and subjecting them to involuntary blood draws.

 

[Gut Shot]

I would say that most people who have HIV and dont know it, also do not have regular physicals or doctors visits.

good idea on paper, bad in practical use.

Perhaps not regular, but huge numbers of people in this country have to undergo physicals for employment. That's nothing to sneeze at.

One of the major problems that the CDC and other public health offices have had to deal with is that it's very, very difficult to get an accurate epidemiological grasp on HIV. Between the variability in reporting, the long latency period, and the life-prolonging effects of HAART, it's difficult to say who and/or how many have HIV at any given moment. In the early 1990's, for instance, the consensus reached through multiple estimations was that there were 600,000-900,000 people with HIV in America. That's a rather large range.

Fifteen years ago these same agencies were hoping to "break the back" of HIV in this country by 2005. That hasn't happened. For a variety of reasons HIV seems to have reached a steady-state in this country... for the time being, at least.

More research will be needed, but I think it's entirely possible (perhaps even likely) that greatly expanding HIV testing will end up being cost effective. Between lost life, lost productivity, the cost of HAART and the cost of treating all the AIDS illnesses, HIV takes quite a toll.

By the by, an excellent summary of HIV epidemiology can be found here.

 

[McDoctor]

The government is just becoming more on more invasive on personal freedom.

In the midwest, central and southern illinois, aids cases are about 1:10,000. That does not do anything close to merit mandatory testing.

Let's not give up our privacy so easily.

Take it easy.

The CDC is just recommending that we offer routine testing to all patients who present for routine health exams. This is similar to the manner that the NCEP guidelines recommend routine cholesterol screening every 5 years starting at age 20. (I actually question the cost effectiveness of the latter for individuals under the age of 30 given the general tendency in the medical community to over-prescribe statins.)

This will not lead to the fiscal decline of healthcare as we know it, nor will it lead to government intrusion into our privacy. What it does provide is the opportunity to offer the test as part of a broad health initiative, rather than relying on a patient to disclose a history of high risk behavior.

I just want to point out that you can't possibly know the true prevalence of AIDS in the midwest without having wider availability of testing. I suspect that the only people who utilize testing as it is currently available are people who continue to take part in high risk behavior. There is a whole segment of middle to upper class professional population who won't disclose a remote history of high risk behavior to their physicians that would benefit from this initiative to implement routine testing.