Researchers suggest HIV screening be routine

Finding the virus early said to add over a year to life

February 10, 2005|By Erika Niedowski | Erika Niedowski,SUN STAFF

At a time when up to 280,000 Americans are unaware they have HIV, screening for the AIDS-causing virus should become a routine part of medical care, two independent research teams have concluded.

The scientists found that identifying HIV infections early through expanded testing can add more than a year to an infected patient's life and prevent the disease's spread - at a cost comparable to other common screenings, such as those for breast cancer or high blood pressure.

Although federal guidelines call for routine HIV testing in high-risk groups, the new studies say that approach doesn't go far enough.

"The whole message that we're really trying to convey is: It's not about `Who should we test?' It's about `We should test everyone,'" said Dr. Rochelle P. Walensky, an infectious disease specialist at Massachusetts General Hospital and co-author of one of the reports.

The findings, published today in The New England Journal of Medicine, get to the root of a critical issue in the fight against HIV and AIDS: how to find and treat those who don't know they're infected.

A quarter to a third of the nation's approximately 900,000 HIV-positive people are unaware they have the virus. That group accounts for up to 20,000 new infections a year, according to the Centers for Disease Control and Prevention in Atlanta.

"It's a sign that we've got to rethink the whole public health approach to HIV testing in this country," said A. David Paltiel of the department of epidemiology and public health at the Yale University School of Medicine and lead author on one study.

The most common method of HIV transmission, by far, is unprotected sex between men, followed by intravenous drug use. But the disease reaches far beyond those groups. Of the estimated 43,100 people in the U.S. who were diagnosed with AIDS in 2003, nearly a third were exposed through heterosexual sex. Among women, sex with HIV-positive men is the primary means of infection.

"This whole epidemic is no longer confined to an easily identifiable risk group," Paltiel said. "This idea of targeting [screening] simply isn't working."

The CDC has recommended targeted testing for those who engage in risky behaviors along with routine testing in populations with an HIV infection rate of 1 percent or higher - such as those in homeless shelters, hospitals or clinics that treat other sexually transmitted diseases. More recently, the agency has endorsed wider screening, even in lower risk groups.

The new research suggests that patients could be screened just one time, or every three to five years. A simple blood test - or a newer, rapid oral test - could be performed in a variety of settings, including outpatient clinics and doctors' offices.

"I think the time is right for this to happen," said Dr. Carlos del Rio, associate director of the Emory Center for AIDS Research in Atlanta, who was not involved in the studies.

Many HIV patients aren't tested until late in the disease, del Rio said, even though they might visit a hospital repeatedly before their diagnosis. He added that the success of antiviral treatments has made early detection more important.

One of the studies, which were based on independent mathematical models, found that identifying and treating HIV early increased a patient's life expectancy by a year and a half.

Moreover, it found that routine one-time testing reduced the annual rate of transmission by about 20 percent. Without screening, the researchers estimated, an infected man who has sex with other men would transmit the virus to at least one sexual partner.

"There's benefit to the HIV patient as an individual but also to the community," said Gillian D. Sanders, associate professor of medicine at Duke University Medical Center and lead author of that study.

In terms of cost, she said, routine testing would be comparable to colon or breast cancer screenings, both of which have become standard in primary health care. The test and counseling would run about $40 to $50, Sanders said.

Still, the researchers acknowledge, making HIV screening routine would come at a steep price to the health care system.

"Just because you show that something pays a good return on investment, which this does, doesn't mean it's going to be cheap," Paltiel said.

In 2002, the Massachusetts Department of Public Health implemented routine voluntary HIV testing at four urgent-care centers in cities with among the highest infection rates. Of the 3,068 people screened in the program's first year, 60 tested positive for the virus.

That infection rate - 2 percent - was twice the rate the CDC has generally used as the threshold for routine screening.

"Sixty doesn't sound like a lot," said Walensky, who was involved with the program. "But 60 can transmit to 60 more people."

Though del Rio has long supported widespread HIV screening, he concedes that it poses several challenges.

"HIV testing is not performed right now as a screening test; it's performed as a diagnostic test," he said.

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