Study Shows Value of HIV Screening in Virtually All Health Settings

Voluntary screening for HIV should be a routine part of the medical care of all adults, not just those at high risk, according to a study by researchers at the Yale School of Medicine.

The team reports in the December 5 Annals of Internal Medicine that routine HIV screening is cost-effective, even in communities where as few as two in 1,000 people have undiagnosed HIV infection.

The study provides strong support for U.S. Centers for Disease Control and Prevention guidelines issued in September 2006 that recommend routine HIV screening of all persons age 13 to 64 in all health care settings. The guidelines were based in part on findings of the study team led by A. David Paltiel, professor in the Department of Epidemiology and Public Health at the Yale School of Medicine, and the Yale School of Management.

“HIV screening delivers better value than many other diagnostic tests and treatments that physicians use routinely in daily practice, including screening for breast cancer, colorectal cancer, diabetes and hypertension,” said Paltiel, who cites the roughly 300,000 Americans who do not know they are infected with HIV as the reason to make HIV screening as routine as measuring cholesterol. “Early identification of HIV saves lives.”

Paltiel and his colleagues developed a mathematical model to simulate the events that occur in an HIV-infected person, including detection, treatment, medical expenses, transmitting the disease to others, and death. The model calculated the additional costs due to screening and the additional survival attributable to earlier detection. It also calculated how much life was shortened by HIV infection. The model then estimated the cost per extra year of life gained (cost-effectiveness) from HIV screening.

“The HIV epidemic is no longer confined to a handful of identifiable risk groups, yet current approaches to HIV testing still focus on the old target populations,” said study co-author Kenneth Freedberg, M.D., director of HIV Outcomes Research at the Harvard Medical School, who is also affiliated with the Partners AIDS Research Center at Massachusetts General Hospital.

The authors caution that the study’s findings hinge on the assumption that persons identified with HIV will be linked to state-of-the art, life-saving care. “There is no point searching for needles in haystacks if you merely plan to throw them back in,” said Paltiel. “The CDC’s commitment to expanded HIV screening must be accompanied by an equally bold financial commitment from the state and federal agencies that provide and pay for HIV care.”

The study was supported by grants from the National Institutes of Mental Health, the National Institute of Allergy and Infectious Diseases, the National Institute on Drug Abuse, the Doris Duke Charitable Foundation and the Centers for Disease Control and Prevention.

Other authors on the study include Rochelle P. Walensky and Lauren M. Mercincavage of Massachusetts General Hospital; Bruce R. Schackman of Weill Medical College of Cornell University; and George R. Seage III and Milton C. Weinstein of Harvard School of Public Health.

Citation: Ann Intern Med. 145, 797-806 (December 5, 2006)