Costs and Consequences of the U.S. Centers for Disease Control and Prevention's Recommendations for Opt-out HIV testing, David R. Holtgrave, PLoS Medicine (2007)

In this study, Dr. David Holtgrave examines the cost effectiveness of routine “opt-out” HIV testing, the intervention that the U.S. Centers for Disease Control and Prevention (CDC) recommends, in terms of dollars spent per HIV infection averted. The CDC recommends that all healthcare facilities screen all 13-64 year old patients for HIV as part of routine care for which patients provide general, rather than specific, consent. The CDC guidelines do not recommend pre-test counseling for anyone, or post-test counseling for those who test negative, suggesting post-test counseling to high risk, HIV negative individuals (the CDC does not explain how “high-risk” individuals be identified) to the extent that it does not interfere with routine testing. Dr. Holtgrave compares the cost of “opt-out” testing with three other testing interventions: routine “opt-out” testing that increases HIV risk behavior due to lack of counseling, routine testing with counseling, and testing with counseling that targets healthcare settings that serve populations with higher than average rates of HIV infection.

Dr. Holtgrave concludes that targeted testing with counseling rather than routine “opt-out” testing is the most cost effective testing intervention in terms of dollars spent per HIV infection averted. He also notes that failing to provide post-test counseling to high risk individuals who test negative could reduce the preventative impact of the “opt-out” intervention and increase costs per infection averted. Assuming that failing to counsel high risk individuals has no negative effect, routine testing with counseling is more expensive per infection averted than the CDC-recommended intervention. However, if the potential negative impact of failing to counsel is taken into account, routine testing with counseling is more cost effective per infection averted than “opt-out” testing. While Dr. Holtgrave’s study highlights the cost-effectiveness of providing counseling with testing and targeted testing, Dr. Holtgrave’s analysis is based on mathematical modeling and does not examine the cost-effectiveness of the interventions in actual health care settings.