HIV experts discuss whether U.S. can handle influx of new HIV cases
January 1, 2007
HIV experts discuss whether U.S. can handle influx of new HIV cases
Opt-out testing likely will cause deluge
U.S. HIV providers are bracing themselves for a flood of new HIV patients as hospitals and many doctors respond to the new recommendations by the Centers for Disease Control and Prevention (CDC) of Atlanta, GA, to provide opt-out HIV testing to nearly every patient they see.
About 25 percent of the estimated 1.2 million people in the United States who are living with HIV infection do not know they are infected, says John Bartlett, MD, chief of the division of infectious diseases at the Johns Hopkins University School of Medicine in Baltimore, MD. Bartlett, who also is an editorial advisory board member of AIDS Alert, spoke about the impact of opt-out on U.S. providers at a summit titled, "Opportunities for Improving HIV Diagnosis, Prevention, and Access to Care in the U.S.," held Nov. 29-30, in Washington, DC.
During an era when highly effective treatment is available, it's unacceptable that so many people do not know their HIV status, Bartlett adds.
This problem likely will be resolved through opt-out testing, which public health experts predict will result in an influx of newly-diagnosed HIV patients.
"The question is, 'Can the health care system in the United States manage that?'" Bartlett says. "Most of [the new patients] are on public resources. Most of them are unemployed, and the number of slots in existing clinics for HIV infection may be limited to the point where we can't handle the large number of new cases."
Also, the CDC's new campaign raises questions about HIV prevention, Bartlett says.
The CDC's 5-year plan to cut new infections in half by 2005 ended without any reduction in the estimated 40,000 new infections per year, a rate that has remained stable for 16 years.
"That's humbling, because we make this big advance in therapy, but we don't seem to be able to successfully prevent the disease, either here or in the rest of the world," Bartlett says.
However, early on in the epidemic, there were 160,000 new infections per year, so the reduction to 40,000 was a significant improvement, says David R. Holtgrave, PhD, professor and department chair at Johns Hopkins Bloomberg School of Public Health. Holtgrave also spoke at the recent access-to-care summit.
"Some analyses have shown that over the course of the epidemic, hundreds of thousands of infections have been prevented in the U.S.," Holtgrave says. "The level of investment that's been made is actually less than the medical care costs that have been saved by preventing those infections."
Also, the transmission rates among HIV infected persons to their seronegative partners have dropped from 25 percent in the mid-1980s to 4 percent today, Holtgrave notes.
"So roughly 96 percent or more people living with HIV in the U.S. don't transmit to someone else in a given year," Holtgrave says. "I think that's also another important measure of prevention success at the national level."
The CDC needs a new national prevention plan that contains these key features, Holtgrave recommends:
- Help people become aware of their serostatus.
- Help HIV positive people who engage in high-risk behavior to decrease that risk behavior.
- Help everyone get into care and treatment.
- Help HIV-negative people who are at high- behavioral risk for infection to reduce that behavioral risk.
"Also, we have to invest at the national level in trying to build back up our basic information about HIV," Holtgrave says. "Now about 43 percent of people in the U.S. get at least one basic question wrong on a very straightforward quiz about HIV; we're seeing our national information, our knowledge foundation, crumble, and we have to rebuild that."
One potential way to reduce new infections is through treating sexually transmitted diseases (STDs), circumcision, using pre-exposure prophylaxis, and using topical microbicides, says Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID).
"All of these things will be better implemented when you know whether someone is infected or not and what you can do to prevent them from infecting others," Fauci says.
Some of the more troubling epidemiological data show an increase in HIV and AIDS diagnoses among young Americans, ages 13 to 24, and a disproportionate disease burden among African Americans and young men who have sex with men (MSM), says Kevin Fenton, MD, PhD, director of the CDC's National Center for HIV, STD and TB Prevention. Fenton and Fauci were among the speakers of the summit.
"To put it together, we are beginning to see the face of the epidemic changing," Fenton says. "Our surveillance data and our research data tell us that individuals who are undiagnosed are more likely to be younger and they're more likely to be of a minority background."
Those who are undiagnosed also are more likely to be high-risk heterosexuals, Fenton adds.
The District of Columbia chose National HIV Testing Day to kick-off a campaign to screen everyone, ages 14 to 84, in Washington, DC, for HIV, says Marsha Martin, DSW, another summit speaker and the senior deputy director, HIV/AIDS Administration, Washington, DC, Department of Health.
"We're now in a situation where we have conditions in the District of Columbia where we have the highest AIDS case rates in the country: 179 per 100,000," Martin says. "So with the rates the way they were in D.C., we then embarked on responding to our community's needs, utilizing changes in technology, changes in treatment opportunities, as well as a new understanding of how we can prevent transmission."
In June 2006, the District of Columbia screened more than 16,000 people for HIV and found an early positive rate of 580, which is a 3.5 percent positive reactive response rate, Martin says.
The District has expanded routine HIV testing to unconventional sites, including university student health services, and through partnerships with local organizations, and partnering with media outlets to get the word out, Martin says.
Finding those who are infected should remain a top priority because of the benefits to their individual health once they are diagnosed, notes Michael Saag, MD, a summit speaker and professor of medicine and director of the University of Alabama at Birmingham (UAB) Center for AIDS Research.
At the UAB clinic and other clinics across the country, patients who start care with a CD4 cell count of less than 200, indicating they have advanced disease, have a mortality rate of 35 percent to 50 percent within 8 years, Saag says.
"If they start care with a CD4 count above 200 and start earlier, then we know that their survival is much, much better, on the order of only 4 percent to 8 percent mortality" Saag says. "So there's a medical reason to start early."
Nonetheless, about three-quarters of the patients who show up for care at the UAB clinic have CD4 cell counts of less than 200, and the median CD4 cell count for new patients has been about 150 for the past decade, Saag notes.
"So they're already against the wall in terms of survivability," Saag says. "So that screams at us that we should be testing earlier."
The one group that consistently has shown up for care with higher CD4 cell counts is pregnant women, whose median CD4 cell count has been about 400. This group has had opt-out HIV testing for the last 5 or 6 years, Saag says.
From both public health and public funding perspectives, it makes sense to diagnose people early in the disease.
Data show that the median cost per patient per year for HIV therapy is $18,000 to $19,000 per year, but the costs per person are as high as $40,000 per year if the patient was diagnosed with a CD4 cell count of less than 50, and if the initial CD4 cell count is greater than 350, then the cost per person per year is $12,000, Saag says.
Patients who are diagnosed early in their disease stay healthy longer, they stay active and productive in society, and there is a considerable reduction in their transmission rates because antiretroviral drug therapy reduces their viral loads, making HIV transmission less efficient, Saag says.
"So it's a win-win-win proposition well worth the investment by any cost analysis you want to do," he adds.
That's the case for having opt-out testing for the general populace, but there's a flip side of the coin: when people are diagnosed, they need care and treatment, Saag says.
"In our clinic, we're already at capacity," Saag says.
HIV providers are stretched so thin now in financial and human resources that they cannot adequately care for a large increase in their HIV patient loads, Saag and other experts say.
"If we were to charge and collect everything owed us, we would collect on average $360 per patient per year," Saag says. "For a 1,000 patient clinic, that's $360,000 for a $2.1 million operation."
The UAB clinic has 1,400 patients, and the funding is not sufficient, he adds.
"Clinics like ours have been flat-funded for the last 7 years, despite a 50 percent to 70 percent increase in patient volume," Saag says.
"So the question is, as we appropriately implement these new opt-out testing rules, which are exactly the right thing to do, how are we going to take care of these patients?" Saag says. "Where are the clinics going to find the capacity to do this?"
If 56,000 of the estimated 250,000 HIV infected people who are unaware of their status are tested, then it will cost a little more than $900 million a year to provide care and treatment to that group of newly-diagnosed patients, Holtgrave says.
Providing nearly a billion dollars in additional medical resources to HIV care and treatment should not be seen as a barrier to increased HIV testing, Holtgrave says.
But it is one sign that the opt-out testing plan will cost the U.S. more money than is currently allocated for the care of HIV patients, Holtgrave and other summit speakers say.
"We need a plan in the U.S. to provide that care, provide linkages to that care, and to identify where those resources are going to come from," Holtgrave says.
U.S. HIV providers are bracing themselves for a flood of new HIV patients as hospitals and many doctors respond to the new recommendations by the Centers for Disease Control and Prevention (CDC) of Atlanta, GA, to provide opt-out HIV testing to nearly every patient they see.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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