Opt-Out HIV Testing: What Are We Waiting For?

Although the CDC recommends that HIV testing be performed in all clinical settings unless the patient refuses, several states still require written consent. This study shows why it's time for those laws to change.

An estimated 232,700 people in the U.S. are infected with HIV but do not know it. Many of them will engage with the healthcare system for reasons unrelated to their HIV status, and those visits represent opportunities for testing and awareness. To that end, the CDC has recommended since 2006 that HIV testing be performed in all healthcare settings on every patient aged 13 to 64, unless the patient explicitly declines (i.e., "opt-out" testing). However, for at least several years after that recommendation was issued, the laws in nine states (Alabama, Hawaii, Massachusetts, Michigan, Nebraska, New York, Pennsylvania, Rhode Island, and Wisconsin) continued to require written informed consent. In this modeling analysis, investigators estimated the survival gains that could occur with a change in those laws.

Based on published data from San Francisco (JW AIDS Clin Care Mar 26 2007), the researchers assumed that removing the requirement for written consent would increase the rate of HIV diagnosis by 48.5%. Under that assumption, having the nine states change their laws would result in a higher average CD4-cell count at diagnosis and a mean survival gain of 1.5 years per HIV-infected individual. This in turn would translate into a total of 537,399 life-years gained. (Even with only a 24.8% increase in the rate of diagnosis, 304,765 life-years would be gained.) These survival gains would vanish if the proportion of HIV-infected people who avoided testing exceeded 18.2%.

Comment: The results of this paper are based on modeling, and the estimates may be overly optimistic. Nonetheless, the states that have not yet changed their laws (4 at the time of this writing: Massachusetts, Michigan, Nebraska, and Pennsylvania) should pass legislation immediately to remove the requirement for written consent. Doing so would lead to earlier detection of HIV infection, longer survival times, and fewer new infections, all of which would advance the goals of the recently released National HIV/AIDS Strategy. Given the unacceptably high rate of HIV incidence in this country, we simply cannot wait any longer.

— Carlos del Rio, MD

The Editor-in-Chief of Journal Watch AIDS Clinical Care was involved in the research described here. Consequently, he was not involved in the selection of this article for coverage, nor was he involved in the writing or review of this summary.

Published in Journal Watch HIV/AIDS Clinical Care March 14, 2011

CITATION(S):

April MD et al. Projected survival gains from revising state laws requiring written opt-in consent for HIV testing. J Gen Intern Med2011 Feb 1; [e-pub ahead of print]. (http://dx.doi.org/10.1007/s11606-011-1637-5)