Angela B. Hutchinson

Routine Opt-Out Rapid HIV Screening and Detection of HIV Infection in Emergency Department Patients

CONTEXT The Centers for Disease Control and Prevention (CDC) recommends routine (nontargeted) opt-out HIV screening in health care settings, including emergency departments (EDs), where the prevalence of undiagnosed infection is 0.1% or greater. The utility of this approach in EDs remains unknown. OBJECTIVE To determine whether nontargeted opt-out rapid HIV screening in the ED was associated with identification of more patients with newly diagnosed HIV infection than physician-directed diagnostic rapid HIV testing. DESIGN, SETTING, AND PATIENTS Quasi-experimental equivalent time-samples design in an urban public safety-net hospital with an approximate annual ED census of 55,000 patient visits. Patients were 16 years or older and capable of providing consent for rapid HIV testing. INTERVENTIONS Nontargeted opt-out rapid HIV screening and physician-directed diagnostic rapid HIV testing alternated in sequential 4-month time intervals between April 15, 2007, and April 15, 2009. MAIN OUTCOME MEASURES Number of patients with newly identified HIV infection and the association between nontargeted opt-out rapid HIV screening and identification of HIV infection. RESULTS In the opt-out phase, of 28,043 eligible ED patients, 6933 patients (25%) completed HIV testing (6702 patients were screened; 231 patients were diagnostically tested). Ten of 6702 patients (0.15%; 95% CI, 0.07%-0.27%) who did not decline HIV screening in the opt-out phase had new HIV diagnoses, and 5 of 231 patients (2.2%; 95% CI, 0.7%-5.0%) who were diagnostically tested during the opt-out phase had new HIV diagnoses. In the diagnostic phase, of 29,925 eligible patients, 243 (0.8%) completed HIV testing. Of these, 4 patients (1.6%; 95% CI, 0.5%-4.2%) had new diagnoses. The prevalence of new HIV diagnoses in the opt-out phase (including those diagnostically tested) and in the diagnostic phase was 15 in 28,043 (0.05%; 95% CI, 0.03%-0.09%) and 4 in 29,925 (0.01%; 95% CI, 0.004%-0.03%), respectively. Nontargeted opt-out HIV screening was independently associated with new HIV diagnoses (risk ratio, 3.6; 95% CI, 1.2-10.8) when adjusting for patient demographics, insurance status, and whether diagnostic testing was performed in the opt-out phase. The median CD4 cell count for those with new HIV diagnoses in the opt-out phase (including those diagnostically tested) and in the diagnostic phase was 69/microL (IQR, 17-430) and 13/microL (IQR, 11-15) , respectively (P = .02). CONCLUSION Nontargeted opt-out rapid HIV screening in the ED, vs diagnostic testing, was associated with identification of a modestly increased number of patients with new HIV diagnoses, most of whom were identified late in the course of disease.

A meta-analysis of the effectiveness of alternative HIV counseling and testing methods to increase knowledge of HIV status

Background:Alternatives to conventional HIV counseling and testing (HIV-CT) have been used to improve receipt of HIV test results. Objectives:To determine the effectiveness of alternative HIV-CT methods on the receipt of HIV test results. Methods:Studies were identified by a systematic search of the literature using English-language databases from 1990 to 2005. Studies were included if they used an alternative method for HIV-CT, reported the receipt of HIV test results and had a comparison group. Pooled effect sizes [risk ratios (RR)] were calculated using a random effects model. Results:Seventeen effect sizes (k) were included n = 21 096). Alternative HIV-CT methods included rapid testing (k = 12), oral fluid testing (k = 2), home testing (k = 1), and telephone post-test counseling (k = 2). All alternatives except for oral fluid testing significantly increased receipt of results compared with conventional testing. In stratified analysis, rapid testing was most effective [RR, 1.80; 95% confidence interval (CI), 1.46–2.22] followed by telephone post-test counseling (RR, 1.38. 95% CI, 1.24–1.47). Conclusions:There is strong evidence that clients are substantially more likely to receive their HIV test results with rapid testing than with conventional tests or other alternatives. Therefore, to increase knowledge of HIV status, rapid testing is preferable in settings with low rates of return for test results.

The economic burden of HIV in the united states in the era of highly active antiretroviral therapy : Evidence of continuing racial and ethnic differences

Background:Assessing the economic burden of HIV/AIDS can help to quantify the effect of the epidemic on a population and assist policy makers in allocating public health resources. Objective:To estimate the economic burden of HIV/AIDS in the United States and provide race/ethnicity-specific estimates. Methods:We conducted an incidence-based cost-of-illness analysis to estimate the lifetime cost of HIV/AIDS resulting from new infections diagnosed in 2002. Data from the HIV/AIDS Reporting System of the Centers for Disease Control and Prevention were used to determine stage of disease at diagnosis and proportion of cases by race/ethnicity. Lifetime direct medical costs and mortality-related productivity losses were estimated using data on cost, life expectancy, and antiretroviral therapy (ART) use from the literature. Results:The cost of new HIV infections in the United States in 2002 is estimated at

Comparing the Costs of HIV Screening Strategies and Technologies in Health-Care Settings

36.4 billion, including

Cost-Effectiveness of Pooled Nucleic Acid Amplification Testing for Acute HIV Infection after Third-Generation HIV Antibody Screening and Rapid Testing in the United States: A Comparison of Three Public Health Settings

6.7 billion in direct medical costs and

Updates of lifetime costs of care and quality-of-life estimates for HIV-infected persons in the United States: late versus early diagnosis and entry into care.

29.7 billion in productivity losses. Direct medical costs per case were highest for whites (

Cost-Effectiveness of Finding New HIV Diagnoses Using Rapid HIV Testing in Community-Based Organizations

180,900) and lowest for blacks (

Estimating the lifetime risk of a diagnosis of the HIV infection in 33 states, 2004-2005.

160,400). Productivity losses per case were lowest for whites (

Cost effectiveness of the National HIV/AIDS Strategy goal of increasing linkage to care for HIV-infected persons.

661,100) and highest for Hispanics (

Lifetime costs and quality-adjusted life years saved from HIV prevention in the test and treat era.

838,000). In a sensitivity analysis, universal use of ART and more effective ART regimens decreased the overall cost of illness. Conclusion:Direct medical costs and productivity losses of HIV/AIDS resulting from infections diagnosed in 2002 are substantial. Productivity losses far surpass direct medical costs and are disproportionately borne by minority races/ethnicities. Our analysis underscores economic benefits of more effective ART regimens and universal access to ART.