HIV: More Voluntary Testing Recommended

by John S. James

Summary: Two research articles and an editorial in the New England Journal of Medicine recommend routine HIV testing for most of the U.S. population. The goal is to start treatment early when it can be more effective -- and also to reduce transmission from the hundreds of thousands of Americans who do not know they have HIV

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Two research articles [1,2] and an editorial [3] in the February 10, 2005 New England Journal of Medicine suggested that routine HIV testing be expanded outside of high-risk group to the U.S. general population, or to all but those at lowest risk. Current U.S. CDC guidelines recommend routine use of screening in populations with more than 1% of people infected, but the new articles used different statistical analyses of existing data to show that some HIV screening could be cost effective even in populations with only 0.1% infected -- the prevalence of HIV in the entire U.S. population. For the general public, one-time screening would be most important, but testing every five years or every three years may also be justified for many groups. This HIV testing would have to be voluntary (meaning that individuals could refuse to be tested), or some people would avoid medical care for other conditions in order to avoid the test.

Both studies found that "the effects of screening would extend survival by 1.5 years for the average HIV-infected patient" [3] by catching infection earlier when treatment could be more effective. One of the studies also estimated that "routine one-time screening would reduce the annual rate of transmission by slightly more than 20%" [3] -- because many of the estimated 280,000 Americans who today do not know they have HIV would learn about taking precautions, and those who learn they are negative may be more motivated to make sure they stay that way.

This work was completed before the report on the possible HIV "super strain" in one patient in New York City. If a more dangerous virus is in fact spreading in the U.S. (which is not known as of February 2005), expanded testing could help to protect against it.

The editorial notes that new resources will need to be made available. By coincidence, the Early Treatment for HIV Act, recently introduced in Congress, would help people pay for treatment before they become disabled -- an important part of making expanded testing work (see the following article on early Medicaid treatment).

References

1. Paltiel DA, Weinstein MC, Kimmel AD and others. Expanded HIV screening in the United States -- an analysis of cost-effectiveness. New England Journal of Medicine. February 10, 2005; volume 352, pages 586-595.

2. Sanders GD, Bayoumi AM, Sundaram V and others. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. New England Journal of Medicine. February 10, 2005; volume 352, pages 570-585.

3. Bozzette SA. Routine screening for HIV infection -- timely and cost-effective. New England Journal of Medicine. February 10, 2005; volume 352, pages 620-621.

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