TESTING AND COUNSELING POLICY
HIV Screening and Care: Effect on Clinical Outcomes, Transmission, and Cost
A. David Paltiel, Ph.D., M.B.A.
Of the estimated 1 million Americans who are currently infected with HIV, as many as 250,000 remain unaware of their infection. These individuals receive neither life-prolonging care nor counseling that could prevent the further transmission of the virus. This sobering fact has prompted a reexamination of the public health approach to HIV screening in the United States, culminating in the September 2006 release of new guidelines from the Centers for Disease Control and Prevention (CDC). This presentation reviews the economic evidence base in support of CDCís recommendation of routine, voluntary HIV testing for all persons ages 13 to 64 years in health care settings. Dr. Paltiel discusses the promise and pitfalls of using model-based, cost-effective analysis as a tool to inform public health decisions. He presents recent results demonstrating the cost-effectiveness of routine, voluntary HIV testing for all adults, not just for those who are at extra high risk. Finally, Dr. Paltiel reports on our efforts to document both the dramatic survival gains that have been achieved in patients with HIV disease in the United States and the chronic disparities arising from inadequate detection, linkage, and access to the appropriate care.
CDCís Recommendations for HIV Screening in Health Care Settings
Bernard M. Branson, M.D.
The Centers for Disease Control and Prevention (CDC) estimate that about one-quarter of the 1.0Ė1.2 million persons living with HIV/AIDS in the United States are unaware of their HIV infection. They are unable to access effective treatment, and compared to those who know they are infected, they are more likely to transmit HIV to others. Pregnant women need to know if they are HIV-infected to help prevent HIV transmission to their children and to access care for themselves. Despite past CDC recommendations for HIV testing, many HIV-infected persons encounter the health care system but are not tested for HIV. CDC has revised the recommendations for HIV testing in health care settings to help increase the proportion of HIV-infected Americans who are aware that they are infected and who receive prevention, care, and treatment. The new recommendations advocate voluntary ďopt-outĒ screening in health care settings; incorporate the consent for HIV testing as part of the consent for general care; promote annual rescreening for individuals with risk indications; and enhance the linkages to care and treatment. CDC issued the revised recommendations on September 21, 2006, and is now engaged with numerous professional organizations on the practical strategies for implementation.
Delay From Testing HIV-Positive Until First HIV Care for Drug Users: Adverse Consequences and Possible Solutions
Barbara J. Turner, M.D., M.S.Ed., and John Fleishman, Ph.D.
Our group and others have reported lengthy delays from testing HIV-positive until the first receipt of HIV care. In a national probability sample of HIV-infected persons, 29 percent of 1,540 persons diagnosed with HIV in the early 1990s delayed first care for more than 3 months, and in this group, the mean delay was 1.45 years. Minorities were significantly more likely to delay, while persons with a usual source of care were less likely to delay. Based on the earlier analysis, we hypothesize that illicit drug use is associated with the increased delay in HIV care. We also hypothesize that this delay will put others at risk through unprotected sex.
Among 1,330 persons in the sample that we previously studied and who responded to questions about drug use, 41 percent of hard-drug users (i.e., crack, cocaine, opioid drugs) delayed HIV care more than 3 months compared with 27 percent of non-drug users. After an adjustment for demographic factors, hard-drug users had 83-percent higher odds of a more than 3-month delay (95-percent confidence interval 1.24-2.70) versus non-drug users, whereas other types of drug abuse (e.g., sedatives, inhalants, amphetamines, marijuana) were not associated with an increased delay. Among those with a more than 3 month-delay, the duration of delay did not differ by drug use group. Having a usual source of medical care was not significantly associated with the severity of drug use, but it was associated with the lower adjusted odds (0.59 [0.48-0.75]) of a more than 3-month delay until first HIV care, regardless of drug use. A later survey of 1,421 patients in this national sample addressed sexual risk-taking. Unprotected sex in the past 6 months was reported by fewer persons who used no drugs (20.7 percent) or only marijuana (28.0 percent) than persons using hard drugs (38.5 percent) or other drugs (40.6 percent). After adjustment, both hard-drug users and other-drug users (except marijuana) had more than twofold greater adjusted odds of recent unprotected sex than non-drug users (p<0.001).
We conclude that after testing HIV-positive, drug users are more likely to delay initiating HIV care and are likely to continue to spread the infection to their partners through unprotected sex. Because drug users with a usual source of medical care appear to initiate HIV care more quickly, these data support increased efforts to link drug users to a longitudinal source of medical care.