Targeted HIV Testing More Effective than CDC Mass Testing Proposal

David Holtgrave, PhD

A targeted campaign of testing and counseling aimed at those who are at high risk for HIV would be more effective than the mass patient screening proposed by the Centers for Disease Control and Prevention (CDC), according to an analysis by David Holtgrave, PhD, an expert on HIV prevention at the Johns Hopkins Bloomberg School of Public Health. Holtgrave determined that the CDC’s testing strategy is likely to cost $864 million for one year. For the same price, a targeted testing and counseling approach would identify more than three times as many people with HIV and could prevent four times as many new HIV infections compared to the CDC’s testing strategy. Holtgrave’s study is the first to examine the cost-effectiveness of the CDC’s testing plan and is published in the June 2007 edition of the journal PLoS Medicine.

The CDC estimates that 25 percent of Americans with HIV do not know they are HIV positive. Because they are unaware, they do not seek treatment and are at greater risk of spreading HIV to others. To identify more Americans with HIV, the CDC has recommended that doctors in the United States test all patients aged 13 to 64 for HIV at every health care visit, unless the patient opts out, or specifically declines to be tested. In order to meet the demands of more testing, doctors can forgo the HIV risk reduction counseling that usually accompanies HIV testing.

“While the CDC’s recommended opt-out testing offers some public health benefit, the data shows there would be substantially more benefit from a more targeted program that includes rather than discards risk reduction counseling—including more diagnosed infections and more transmissions prevented,” said Holtgrave, who is professor and chair of the Bloomberg School’s Department of Health, Behavior and Society.

Using standard methods of cost-effectiveness analysis, Holtgrave estimates that CDC’s recommended opt-out testing program would cost $864 million. For the same cost, a program of targeted counseling and testing would diagnose 188,170 new HIV infections, compared with 56,940 that would be detected through CDC’s testing plan, assuming 1 percent of the population tested is HIV positive. Additionally, targeted counseling and testing would prevent an estimated 14,553 new HIV infections at a cost of $59,383 per infection prevented, compared to 3,644 from opt-out testing at a cost of $237,149 per infection prevented. Further, Holtgrave says that targeted testing and counseling perform better than opt-out testing in several key outcomes even when the rate of HIV infection in the community is 0.3 percent.

“It is important that everyone living with HIV knows their serostatus so that they might access life-saving HIV treatment. The question now is to determine the most effective testing strategies for identifying people with HIV. Our work sought to answer that question,” said Holtgrave.