Costs and consequences of the US Centers for Disease Control and Prevention's recommendations for opt-out HIV testing.
BACKGROUND
The United States Centers for Disease Control and Prevention (CDC) recently recommended opt-out HIV testing (testing without the need for risk assessment and counseling) in all health care encounters in the US for persons 13-64 years old. However, the overall costs and consequences of these recommendations have not been estimated before. In this paper, I estimate the costs and public health impact of opt-out HIV testing relative to testing accompanied by client-centered counseling, and relative to a more targeted counseling and testing strategy.


RESULTS
Basic methods of scenario and cost-effectiveness analysis were used, from a payer's perspective over a one-year time horizon. I found that for the same programmatic cost of US$864,207,288, targeted counseling and testing services (at a 1% HIV seropositivity rate) would be preferred to opt-out testing: targeted services would newly diagnose more HIV infections (188,170 versus 56,940), prevent more HIV infections (14,553 versus 3,644), and do so at a lower gross cost per infection averted (US$59,383 versus US$237,149). While the study is limited by uncertainty in some input parameter values, the findings were robust across a variety of assumptions about these parameter values (including the estimated HIV seropositivity rate in the targeted counseling and testing scenario).


CONCLUSIONS
While opt-out testing may be able to newly diagnose over 56,000 persons living with HIV in one year, abandoning client-centered counseling has real public health consequences in terms of HIV infections that could have been averted. Further, my analyses indicate that even when HIV seropositivity rates are as low as 0.3%, targeted counseling and testing performs better than opt-out testing on several key outcome variables. These analytic findings should be kept in mind as HIV counseling and testing policies are debated in the US.
Holtgrave
David R
DR
Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America. dholtgrave@jhsph.edu
D015492:AIDS Serodiagnosis / Q000191:economics / Q000523:psychology / Q000706:statistics & numerical data; D000293:Adolescent; D000328:Adult; D002487:Centers for Disease Control and Prevention, U.S.; D003362:Cost-Benefit Analysis; D003376:Counseling / Q000191:economics; D003955:Diagnostic Tests, Routine / Q000191:economics / Q000523:psychology / Q000706:statistics & numerical data; D018562:Disease Transmission, Infectious / Q000517:prevention & control; D042241:Early Diagnosis; D005260:Female; D019983:Guideline Adherence; D015658:HIV Infections / Q000175:diagnosis / Q000517:prevention & control / Q000523:psychology / Q000635:transmission; D006679:HIV Seropositivity / Q000175:diagnosis / Q000453:epidemiology; D015528:HIV Seroprevalence; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006291:Health Policy / Q000191:economics; D006801:Humans; D007258:Informed Consent; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D010342:Patient Acceptance of Health Care; D009629:Person-Centered Psychotherapy / Q000191:economics; D017410:Practice Guidelines as Topic; D011634:Public Health / Q000191:economics; D012306:Risk; D018570:Risk Assessment / Q000191:economics; D012309:Risk-Taking; D016312:Treatment Refusal; D014481:United States / Q000453:epidemiology