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Response to Holtgrave, DR “Cost and Consequences of the US CDC’s Recommendations for Opt-out HIV Testing”

Posted by plosmedicine on 30 Mar 2009 at 05:16 GMT

Author: Bernard Branson
Position: Associate Director for Laboratory Diagnostics
Institution: CDC - Division of HIV/AIDS Prevention
E-mail: bmb2@CDC.GOV
Additional Authors: Dr. Robert Janssen
Submitted Date: November 16, 2007
Published Date: November 19, 2007
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Based on his analysis of hypothetical HIV testing scenarios, Holtgrave endorses targeted counseling and testing that has been recommended by CDC since 1993 over routine opt-out testing in health-care settings as recommended by CDC in 2006. We agree that HIV counseling and testing in venues that serve high-risk patients continue to be worthwhile. CDC revised its recommendations for HIV testing in health care settings, however, because previous recommendations for targeted testing were impractical and widely ignored.

We believe the scenarios upon which the analysis is based are implausible. Holtgrave’s targeted counseling and testing case is an idealized scenario that assumes existing evaluation activities can, at no additional cost, identify health-care settings in which at least 50% of patients are at high-risk for HIV infection; HIV prevalence is, on average, 10%; and 0.63% of patients are newly diagnosed with HIV. Other than venues in which HIV testing is already conducted routinely, such as STD clinics and substance abuse treatment centers, it is difficult to envision what such settings might be, or to assume that providers serving such a high-risk clientele are not already conducting HIV screening. It is unclear whether Holtgrave’s targeted scenario focuses on health care settings or includes outreach, but the only outreach testing that has achieved such high rates of HIV are partner services or social networks. Costs for such labor-intensive services are not included in the model. In contrast, in his opt-out testing scenario, 0.087% of patients are newly diagnosed with HIV (a diagnostic yield less than that at which screening is recommended) and the average HIV prevalence is only 0.2%. The prevalence of HIV among all 13 to 64 year olds in the United States is closer to 0.5%.

Dr. Holtgrave’s analysis also does not consider whether the alternatives are equally feasible or equally acceptable to patients and providers. With targeted testing, some patients say they refuse the HIV test because they fear the associated stigma [1], and providers express concern that recommending an HIV test will offend or alienate their patients [2]. Numerous studies have documented high yields from HIV screening in emergency departments (EDs), but rapid HIV screening programs conducted in three urban EDs illustrate outcomes quite different from those predicted by the model [3]. Two programs conducted counseling and testing, and the third, routine screening. The counselor-based models were able to test 1,709 and 1,288 patients and identify 13 and 19 newly-diagnosed HIV infections, respectively. The routine screening ED tested 6,368 patients and identified 65 new HIV diagnoses during the same time period. Although Holtgrave implies that HIV counseling and testing could be expanded by simply adding more counselors, the American College of Emergency Physicians stipulates that HIV screening, when appropriate, must be practical and feasible for emergency settings, and cannot interfere with the primary acute care mission [4]. Because 90% of hectic trauma centers operate at or above capacity, ambulances are diverted while multiple patients are crowded into treatment rooms and boarded in hallways [5]. No space exists for the numerous additional confidential counseling sessions required for the targeted counseling and testing scenario.

The U.S. Preventive Services Task Force review found insufficient evidence to recommend for or against routine testing and recommended testing based on individual risk factors or local prevalence, but acknowledged that (1) local prevalence data are often not readily available; (2) one potential effect of routine testing is to decrease the stigma associated with HIV screening, and (3) by eliminating the need for risk assessment or local prevalence information, universal testing is theoretically less burdensome and easier to put into practice [6].

Counseling with testing has been an effective strategy that CDC continues to endorse when it is feasible. Persistently, an estimated 25% of infected persons remain unaware they have HIV. Each year, 40% of those diagnosed with HIV have AIDS within 12 months of their HIV diagnosis, indicating late detection of their HIV infection. CDC’s pragmatic recommendations enable health-care providers to incrementally adopt a feasible HIV testing strategy so that, when HIV-infected patients encounter the health-care system, they learn they are infected, can take advantage of life saving treatment, and reduce their risk of transmitting HIV to others.

Bernard M. Branson, M.D.
Associate Director for Laboratory Diagnostics
Robert S. Janssen, M.D.
Division of HIV/AIDS Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention


1. Hutchinson AB, Corbie-Smith G, Thomas SB, Mohanan S, del Rio C. (2004) Understanding the patient's perspective on rapid and routine HIV testing in an inner-city urgent care center. AIDS Educ Prev 16:101-114.
2. Burke RC, Sepkowitz KA, Bernstein KT, Karpati AM, Myers JE, et al. (2007) Why don't physicians test for HIV? A review of the US literature. AIDS. 21:1617-1624.
3. CDC. (2007) Rapid HIV testing in emergency departments--three U.S. sites, January 2005-March 2006. MMWR Morb Mortal Wkly Rep 56:597-601. Available: Accessed 29 August 2007.
4. American College of Emergency Physicians. (2007) Policy statement: HIV Testing and Screening in the Emergency Department. Available: Accessed 29 August 2007.
5. Kellermann AL. (2006) Crisis in the emergency department. N Engl J Med. 355:1300-1303. Available: Accessed 29 August 2007.
6. Chou, R, Huffman, L. (2007) Screening for Human Immunodeficiency Virus: Focused Update of a 2005 Systematic Evidence Review for the U.S. Preventive Services Task Force. AHRQ Publication No. 07-0597-EF-1. Available: Accessed 29 August 2007.

No competing interests declared.