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. Methods and Findings: 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. Scenario and cost-effectiveness analyses found that for the same programmatic cost, targeted counseling and testing would diagnose more people living with HIV and prevent more HIV infections than opt-out testing. Background.: About a quarter of a million people in the United States do not realize they are infected with HIV. Because they are unaware of their infection, they don't get the medicines they need to stay healthy, and they may also be transmitting HIV, the virus that causes AIDS, to others unwittingly. How can public health professionals best reach such people to offer them an HIV test? There are a number of different schools of thought, the two most common of which are studied in this paper. Why Was This Study Done?: The researcher, David Holtgrave, wanted to know which of these two different approaches would be better at reaching people with undiagnosed HIV infection over the course of a one-year period. He also wanted to know the costs of each approach, and which might be better at curbing the spread of HIV. What Did the Researcher Do and Find?: He used two research techniques. One is called “scenario analysis,” which involves trying to forecast the consequences of several different possible scenarios. The other is called “cost-effectiveness analysis,” which involves comparing the costs and effects of two or more different courses of action. What Do These Findings Mean?: These findings suggest that targeted counseling and testing would be better than opt-out testing for reaching people with undiagnosed HIV infection and for helping to stop the spread of the virus. Opt-out testing, says the author, might even make some people increase their risky behavior. For example, if someone is injecting drugs, is given an opt-out HIV test, but is never questioned about substance use or counseled, and gets an HIV-negative result, they could easily conclude that their drug injecting is not putting them at risk of becoming HIV positive. Additional Information.: Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040194.