Just in time for World AIDS Day — held every year on December 1st to remember the nearly 30 million people who have died since the epidemic began in the late 1970s — the US Preventative Services Task Force has released new guidance on routine HIV testing. This is first time since 2005 that the Task Force has updated its HIV testing recommendations.
Previously, the Task Force recommended that only those at increased risk of acquiring HIV get tested routinely. People considered to be at increased risk of infection in the US include gay men, injection drug users, commercial sex workers and those with a history of sexually transmitted infections.
In its 2005 guidance, the Task Force also recommended that all pregnant women be tested. This was not because pregnant women in the US are at high risk of infection, but because identifying and treating pregnant women who are living with HIV/AIDS can greatly reduce the likelihood that they will transmit the virus to their children.
At that time, the Task Force did not recommend routine HIV testing for everyone else. This was in part because of concerns about cost effectiveness. The cost per case of HIV identified by routine screening of all adults in the US was estimated to be about $100,000. While those who did not otherwise know that they were living with HIV/AIDS would benefit, the Task Force concluded that this did not justify the enormous public cost.
Those recommendations have now changed. In a updated document available for public comment on its website, the Task Force recommends that all individuals between 15 and 65 be tested for HIV, not just pregnant women or those at increased risk.
This stunning reversal comes in the wake of new data showing that routine screening for HIV has clear public health benefits. Namely, identifying and treating those living with HIV/AIDS as soon as possible prevents the spread of the virus to others. In a study of couples where one had HIV and the other did not, for example, treating the infected partner lead to a 96% reduction in viral transmission.
Given this, epidemiological and economic models now suggest that a universal ‘test and treat’ strategy — where everyone is tested for HIV once a year and treated immediately if they are infected — could eliminate the AIDS epidemic at relatively modest cost. The cost per case of HIV identified by routine screening remains high, but when you include the potential savings of preventing new cases of HIV/AIDS the economic benefits become clear. Each dollar spent on universal testing and treatment may save as much as two dollars in future costs.
Achieving this requires full implementation of test and treat programs; everyone needs to be tested and everyone with HIV needs to be treated. Fall short of that and epidemic will be slowed but not stopped. Moreover, the amount of money that we currently spend on HIV treatment might actually increase dramatically if too many people remain untested.
This will be a challenge. Of the 1 million people living with HIV/AIDS in the US, nearly a third do not know that they are infected. They do not seek HIV testing because they do not consider themselves at risk, or because they fear stigmatization and discrimination once they tell their health care provider that they are gay, use drugs, or engage in prostitution.
Unfortunately, untested but infected individuals are far more likely than those who know their HIV status to pass the virus on to others. These blissfully unaware people account for more than half of all new cases of HIV transmission. Identifying and treating them must be our primary goal.
Thankfully, the new Task Force recommendations will help. To date, the greatest barriers to routine HIV testing has been a financial one. Most insurance plans do not cover clinical tests and services unless there is a clear reason for providing them. This means that many doctors cannot be reimbursed for ordering an HIV test unless the patient was pregnant or considered at high risk of infection. But again, many of those who are unaware that they are living with HIV/AIDS fall outside of one of the known risk groups or are afraid to tell their doctor that they are at risk. Thus, there has been no financial incentive for doctors to offer HIV testing to most of their patients.
That is no longer the case. Under the Affordable Care Act, health insurers must cover all preventative services recommended by the US Preventative Services Task Force. Financial barriers to routine HIV testing in the clinic will thus be removed, bringing us one step closer to universal screening and treatment.
Of course, some barriers will still remain. Some doctors may be unaware of the new testing recommendations, while others may not understand the importance of routine HIV testing of their patients. Many patients may refuse to be tested, while others may not have health insurance or a primary care physician who can offer testing. Continuity of care could also a problem; it will be important to ensure that those who are diagnosed with HIV/AIDS are provided with appropriate treatment and follow up care.
But these barriers are not insurmountable, and current changes in health care policy are beginning to address the structural issues that prevent many Americans from seeking routine medical care. For the first time in three decades, an end to the AIDS epidemic may actually be in sight.
[This blog entry was originally presented as an oral commentary on Northeast Public Radio on November 29, 2012. It is also available on the WAMC website.]