Epidemiology, Screening and Public Policy

Jul 24, 2017 | 0 comments

Jul 24, 2017 | Miscellaneous | 0 comments

Epidemiology, Screening and Public Policy


Opt-out testing for human immunodeficiency virus in the United States: progress and challenges
Summary of the controversial recommendations

The Centre for Disease Control and Prevention (CDC) recommended testing of Human Immunodeficiency Virus (HIV) for all people aged between 13 years to 64 years in all the healthcare settings for screening. They include:

  • All patientsaged between 13-64 years should be screened in all healthcare settings. Theseincludepatients in clinic, hospitaladmissions, andemergencydepartments in which the screening yield has a likelihood of being 1 out of 1000 screenedpatients (Palella et al, 1998; Walensky, 2006; Sanders et al, 2005).
  • In the clinical settingshaving a less than 0.1% prevalence, they should conducttargettesting that is based on HIV risk, including behavioural risks, STDs, Tuberculosis patients, andrecentimmigrants from countries with highprevalence (Bartlett et al, 2008).
  • The patients with risks that are knownfor HIV infection should be testedannually at minimum, andtheyincludepeoplewhoexchangemoneyordrugsforsex, injectiondrugaddictsand their sexualpartners, menwhohavesexualintercourse withmen,sexpartners of personsinfectedwith HIV, heterosexualsand their sexpartners (Bartlett et al, 2008).

What makes them controversial and whether you feel they are justified?

The screening recommendations by CDC are controversial in many ways. First, the general consent for health care which also encompasses HIV screening in healthcare stings, states that the patients should be informed either in writing or orally that HIV test will be done that they may decline testing or obtain more information concerning the test (Bartlett et al, 2008). However, according to the recommendations provided by CDC, all patients aged between 13-64 years should be screened in all healthcare system. healthcare settings. There is a discord since compulsory testing of patients in all health care settings be it through admissions or in the emergency department is not in line with the requirement for pre counselling of the patients and getting their opinion of getting tested or declining (Bartlett et al, 2008).

As much as the recommendations are controversial, I believe the recommendations of CDC are justified. It is important to conduct screening of HIV on every patient so that any early detection will be enrolled in antiretroviral therapy immediately to prevent late medication that is dangerous

Describe the epidemiological evidence in support of your position

Surveillance of Domestic HIV indicates consistently that about 40% of patients receive diagnosis of AIDs within one year after their first test result that was positive (CDC, 2006; CDC, 2003). Natural history of infection by HIV indicates that averagely 7-9 years after infection elapse before diagnosis, in which an individual may transmit HIV unknowingly or fail to get effective therapy. Palella et al (1998) and Walensky (2006) indicated that highly antiretroviral therapy in the first decade in United States has saved approximately 3 million life years. However, averagely survival rate is estimated to be 11 years longer when commencement of treatment to an individual when they has a CD4 count of 320 cells/μL vs 87 cells/μL (Moore, Keruly and Bartlett, 2008).


Identify whether the prevention program you review is population or high-risk based and how that influences your assessment

The prevention program reviewed is population-based, and it has influenced my assessment in many ways. First of all, the program’s recommendations conflicts with the federal and other state agency laws hence difficult to assess properly (Hanssens, 2007; Gostin, 2006; Bayer and Fairchild, 2006). Moreover, there is the absence of the mandated primary HIV prevention counseling (Hanssens, 2007; Gostin, 2006). There is also the persistent stigma that is linked to infection by HIV (Gostin, 2006; Lifson and Rybicki, 2007; Valdiserri, 2007; Holtgrave, 2007; Gruskin, Ahmed and Ferguson, 2008), the fear of discrimination amongst the patients and the general; belief among people that risk-based testing is very cost effective (Holtgrave, 2007).


Bartlett, J. G., Branson, B. M., Fenton, K., Hauschild, B. C., Miller, V., & Mayer, K. H. (January 01, 2008). Opt-out testing for human immunodeficiency virus in the United States: progress and challenges. Jama, 300, 8, 945-51.

Bayer R, Fairchild AL.(2006). Changing the paradigm for HIV testing—the end of exceptionalism. N Engl J Med;355(7):647-649

CDC. (2003). Late Versus Early Testing of HIV—16 Sites, United States, 2000-2003. (July 23, 2003). Jama, 290, 4, 455.

Centers, . D. C. P. (May 01, 2007). Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. Annals of Emergency Medicine, 49, 5, 575-577.

Gostin, LO.(2006). HIV screening in health care settings: public health and civil liberties in conflict? JAMA; 296(16):2023-2025.

Gruskin S, Ahmed S, Ferguson L. (2008). ProviderinitiatedHIV testing and counseling in health facilities—what does this mean for the health and human rightsof pregnant women? Dev World Bioeth;8(1):23-32

Hanssens, C.(2007). Legal and ethical implications of optout testing. Clin Infect Dis;45(suppl4):S232-S239.

Holtgrave DR.(2007). Costs and consequences of the US Centers for Disease Control and Prevention’s recommendations for opt-out HIV testing. PLoS Med. 2007; 4(6):e194.

Lifson AR, Rybicki SL.(2007). Routine opt-out HIV testing. Lancet;369(9561):539-540.

Moore R, Keruly J, Bartlett JG.(2008). Person-years lost by late presentation for HIV care in Maryland. Presented at: 15th Conference on Retroviruses and Opportunistic Infections; February 3-6; Boston, MA. Abstract 805.

Palella FJ Jr, Delaney KM, Moorman AC, et al; (1998). HIV Outpatient Study Investigators. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N Engl J Med.338(13):853-860.

Paltiel AD, Weinstein MC, Kimmel AD, et al. (January 01, 2005). Expanded Screening for HIV in the United States—an Analysis of Cost-effectiveness. N Engl J Med;352(6):570- 585.

Sanders, G. D., Bayoumi, A. M., Sundaram, V., Bilir, S. P., Neukermans, C. P., Rydzak, C. E., Douglass, L. R., … Owens, D. K. (January 01, 2005). Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. The New England Journal of Medicine, 352, 6, 570-85.

Valdiserri RO. (2007). Late HIV diagnosis: bad medicine and worse public health. PLoS Med;4(6): e200.

Walensky RP, Paltiel AD, Losina E, et al. (2006). The survival benefits of AIDS treatment in the United States. J Infect Dis;194(1):11-19.

Walensky, R. P., Weinstein, M. C., Kimmel, A. D., Seage, G. R., Losina, E., Sax, P. E., Zhang, H., … Paltiel, A. D. (March 01, 2005). Routine human immunodeficiency virus testing: An economic evaluation of current guidelines. The American Journal of Medicine, 118, 3, 292-300.