Routine voluntary HIV screening in STD clinic clients: characterization of infected clients

Cost-effectiveness of voluntary HIV screening in Russia

Russia has one of the world's fastest growing HIV epidemics, and HIV screening has been widespread. Whether such screening is an effective use of resources is unclear. We used epidemiologic and economic data from Russia to develop a Markov model to estimate costs, quality of life and survival associated with a voluntary HIV screening programme compared with no screening in Russia. We measured discounted lifetime health-care costs and quality-adjusted life years (QALYs) gained. We varied our inputs in sensitivity analysis. Early identification of HIV through screening provided a substantial benefit to persons with HIV, increasing life expectancy by 2.1 years and 1.7 QALYs. At a base-case prevalence of 1.2%, once-per-lifetime screening cost $13,396 per QALY gained, exclusive of benefit from reduced transmission. Cost-effectiveness of screening remained favourable until prevalence dropped below 0.04%. When HIV-transmission-related costs and benefits were included, once-per-lifetime screening cost $6910 per QALY gained and screening every two years cost $27,696 per QALY gained. An important determinant of the cost-effectiveness of screening was effectiveness of counselling about risk reduction. Early identification of HIV infection through screening in Russia is effective and cost-effective in all but the lowest prevalence groups.

Integrating routine HIV testing into a public health STD clinic

OBJECTIVE

To integrate routine HIV testing into the services offered at a public health department STD clinic and document the rate of acceptance and rate of test positivity during the first 18 months.

METHODS

Testing for HIV was added to the array of tests offered to all patients at the Maricopa County STD clinic. Patients were informed of this new option at registration and were provided with a consent form and instructions to read the form and sign it, unless they did not desire testing. STD clinicians were responsible for insuring that questions regarding testing were answered and that consent forms were signed. HIV prevention was integrated into the general STD preventive messages during the clinical encounter.

RESULTS

Sixty-eight percent of patients accepted testing (12,176 of 17,875). Of these, 68 were HIV-positive, for a rate of 5.6 per 1,000. The positive rate for men was 8.6/1000 and for women 1.2/1,000. The rate for men who reported having sex with men (MSM) was 63.8/1,000. Fourteen of the HIV-positive MSM were co-infected with syphilis. Of the 68 who were HIV-positive, 58 (85.3%) were successfully located, informed of their test results, and referred for HIV treatment and support services.

CONCLUSIONS

HIV testing can be included in the routine battery of tests offered at an STD clinic with high patient acceptance. Routine testing can discover those who are unaware of their HIV-positive status, providing an opportunity for early referral for treatment, counseling to avoid disease transmission, and notification of sexual contacts.

Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy

BACKGROUND

The costs, benefits, and cost-effectiveness of screening for human immunodeficiency virus (HIV) in health care settings during the era of highly active antiretroviral therapy (HAART) have not been determined.

METHODS

We developed a Markov model of costs, quality of life, and survival associated with an HIV-screening program as compared with current practice. In both strategies, symptomatic patients were identified through symptom-based case finding. Identified patients started treatment when their CD4 count dropped to 350 cells per cubic millimeter. Disease progression was defined on the basis of CD4 levels and viral load. The likelihood of sexual transmission was based on viral load, knowledge of HIV status, and efficacy of counseling.

RESULTS

Given a 1 percent prevalence of unidentified HIV infection, screening increased life expectancy by 5.48 days, or 4.70 quality-adjusted days, at an estimated cost of 194 dollars per screened patient, for a cost-effectiveness ratio of 15,078 dollars per quality-adjusted life-year. Screening cost less than 50,000 dollars per quality-adjusted life-year if the prevalence of unidentified HIV infection exceeded 0.05 percent. Excluding HIV transmission, the cost-effectiveness of screening was 41,736 dollars per quality-adjusted life-year. Screening every five years, as compared with a one-time screening program, cost 57,138 dollars per quality-adjusted life-year, but was more attractive in settings with a high incidence of infection. Our results were sensitive to the efficacy of behavior modification, the benefit of early identification and therapy, and the prevalence and incidence of HIV infection.

CONCLUSIONS

The cost-effectiveness of routine HIV screening in health care settings, even in relatively low-prevalence populations, is similar to that of commonly accepted interventions, and such programs should be expanded.

Effective detection of HIV

Biomedical advances, new HIV testing technologies, and policy shifts in the last 15 years have created substantial new challenges and opportunities for service providers, policy makers, and researchers regarding broad scale identification of HIV-seropositive persons. Effective HIV testing will be achieved when we: (1) increase the number of high-risk persons tested; (2) decrease the time from HIV infection to detection; (3) increase testing acceptability; (4) increase the proportion of individuals tested who receive their results; and (5) increase the proportion of individuals tested seropositive who are linked to care. Strategies to enhance effectiveness include implementing new testing technologies and delivery modalities; expanding access to client-controlled testing; targeting providers' knowledge, attitudes, and behaviors regarding HIV testing; mainstreaming HIV testing as routine clinical care; targeting persons who engage in high-risk behaviors and those in high-risk groups; and implementing a national behavioral surveillance system. Addressing these challenges will improve HIV detection in the United States, which is vital to both HIV prevention and treatment.

Patterns of Chlamydia trachomatis testing and follow-up at a University Hospital Medical Center

OBJECTIVE

Although testing for Chlamydia trachomatis is encouraged and increasingly practiced at sexually transmitted disease (STD) and family planning clinics, patterns of testing and follow-up in other settings are not well described. To begin to address these issues, we performed a chart review of patients with a positive laboratory test for C. trachomatis at a major university medical center.

METHODS

Chart review of medical records for all patients with positive laboratory tests for C. trachomatis during calendar year 1996.

RESULTS

Of 326 patients with positive tests, 95% were female and 5% were male. Median age was 22 for females and 25 for males. Most positive C. trachomatis test results were from the emergency room (ER)/walk-in clinic (55%) or patients receiving obstetric/gynecologic (OB/GYN) care (31%). While most C. trachomatis tests performed were on patients who had symptoms, patterns of treatment varied between sites. Fifty-seven percent of ER/walk-in patients received empiric antibiotics at the initial visit versus 36% of patients under OB/GYN care. Among patients with positive screening tests seen in the ER/walk-in clinic, 32% of patients had no treatment documented versus 14% of OB/GYN patients. Four percent of women with positive tests who did not receive therapy at the time of their initial evaluation developed pelvic inflammatory disease in the interval between testing and return to the medical center.

CONCLUSIONS

Of the patients with positive chlamydial screening tests, the proportion not treated was similar to that found in studies performed in STD clinics.

Predictors of human immunodeficiency virus counseling and testing among sexually transmitted disease clinic patients

OBJECTIVES

To determine the predictors of prior or current, and repeat human immunodeficiency virus (HIV) testing.

STUDY DESIGN

Cross-sectional survey.

METHODS

Sexually transmitted disease (STD) clinic patients who participated in a blinded HIV seroprevalence survey completed a voluntary questionnaire regarding their reasons for accepting or declining HIV testing.

RESULTS

Eighty-seven percent of participants reported a previous HIV test or were HIV testing the day they completed the questionnaire. African Americans were less likely to have been HIV tested (adjusted odds ratio 0.3, 95% confidence limits, 0.1, 0.8). The most common reasons for testing were to be reassured and to receive medical care if infected. The most common reason for not testing was that nontesters did not think that they were infected. Repeated testing was reported by 51% of the participants and was more frequent among patients who were older or members of high-risk groups (P < 0.05). Patients tested repeatedly to confirm a prior HIV test result or because of continued risky behavior.

CONCLUSIONS

Testing for HIV is frequent among STD clinic patients but less so among African Americans. Receipt of medical care appears to be an important motivation for HIV testing, whereas lack of perceived risk may discourage testing. Continued high-risk behavior contributes to repeat HIV testing.

Positive screening tests for gonorrhea and chlamydial infection fail to lead consistently to treatment of patients attending a sexually transmitted disease clinic

BACKGROUND AND OBJECTIVES

Patients attending sexually transmitted disease (STD) clinics are frequently screened for gonorrhea and chlamydial infection. To determine the efficiency of these screening efforts as a component of STD control, we evaluated treatment outcomes of patients with positive cultures who had not received presumptive treatment at their initial visit.

GOALS

To determine the treatment outcomes of patients screened for STDs who have positive test results.

STUDY DESIGN

Retrospective chart review of the computerized medical record.

RESULTS

Between January 1, 1994 and June 30, 1995, 24,823 patients were tested for gonorrhea, of whom 19.3% (4791) had positive cultures. Of patients with positive gonorrhea cultures, 564 (11.8%) had positive screening cultures and did not receive therapy at the time of evaluation. Similarly, screening chlamydial cultures were positive in 1539 (10.9%) of 14,162 patients screened for chlamydial infection. Forty-four percent (677) of these did not receive presumptive treatment for chlamydial infection at their initial visit. Overall, 20% of patients with positive cultures failed to return to the clinic for treatment within 30 days of screening. Of those who did return, 30% did so only after at least 2 weeks had elapsed.

CONCLUSIONS

A substantial proportion of patients with positive screening tests for gonorrhea and chlamydial infection fail to comply with follow-up recommendations and thus are likely to remain infectious. Methods must be sought to enhance patient compliance with follow-up of test results and treatment if indicated.

Early intervention for human immunodeficiency virus in Baltimore Sexually Transmitted Diseases Clinics. Impact on gonorrhea incidence in patients infected with HIV

BACKGROUND

High incidences of sexually transmitted diseases (STD) after posttest counseling have been documented in patients diagnosed with human immunodeficiency virus (HIV) in Baltimore STD clinics. In July 1991, the authors instituted an HIV early intervention program providing long-term medical care and social work services. This study compares the incidence of gonorrhea after post-HIV+ test counseling in patients diagnosed with HIV before and after the institution of the early intervention program.

METHODS

Medical records of a cohort composed of all patients newly diagnosed with HIV and those who underwent posttest counseling for HIV in 1991 to 1993 in two Baltimore STD clinics were reviewed. Patients were offered early intervention medical and social work services. Gonorrhea incidence in this cohort was compared to a historical cohort diagnosed and counseled for post-HIV+ testing in 1988 to 1989 who were not offered early intervention services.

RESULTS

The mean follow-up time was 418 days (range, 26 to 703 days). After post-HIV+ test counseling, gonorrhea developed in 39 of 468 (8.3%) men in the 1989 cohort and 13 of 400 (3.3%) men in the 1991 to 1993 cohort. Controlling for variable length of follow-up, the 1991 to 1993 cohort had a relative risk of 0.442 for the development of gonorrhea during the study period (95% confidence interval, 0.225 to 0.790; P = 0.006). Incident gonorrhea after post-HIV+ test counseling also was associated with a prevalent gonorrhea condition at the time of HIV diagnosis (RR = 3.02; 95% CI, 1.75 to 5.23; P = 0.0001) and failure to return for post-HIV+ test counseling as scheduled (RR = 2.27; 95% CI, 1.17-4.43; P = 0.013). After adjustment for gonorrhea at the time of HIV diagnosis and failure to return for scheduled posttest counseling, the difference in gonorrhea incidence between men in the two cohorts remained statistically significant (RR = 0.494; 95% CI, 0.260 to 0.941; P = 0.032). In comparison, overall gonorrhea rates in Baltimore changed little between 1988 and 1993. No significant difference was found in gonorrhea incidence in women, which may have been the result of active gonorrhea screening during the 1991 to 1993 period, which was not performed in 1988 to 1989.

CONCLUSIONS

Providing clinical care to persons with HIV may facilitate the reduction of high-risk behaviors that lead to incident STDs and further HIV transmission.

Assessment of self-report in HIV surveillance: a pilot study

The basis of HIV exposure category classification was investigated among selected cases of newly diagnosed HIV infection. Questionnaires seeking specific information on patient-reported exposure to HIV were forwarded to doctors who had requested the HIV antibody test for patients who met the study sample criteria. The cases of interest were those newly diagnosed between 1 January and 31 October 1991 and notified to state and territory health authorities as having been attributed to exposures to HIV other than male homosexual contact or receipt of blood, blood products or tissue. A total of 158 questionnaires was forwarded and 59 per cent were returned. Among the returned questionnaires included in the study sample, exposure to HIV on the original notification to the health authority was given as injecting drug use (8 per cent, 3 of 37), heterosexual contact (46 per cent, 17 of 37), or unavailable (46 per cent, 17 of 37). A clear basis for HIV exposure category classification was provided on the questionnaires for 70 per cent (7 of 10) of cases among women, whereas among men whose infection was attributed to heterosexual contact, a basis for exposure category classification was specified for only 43 per cent (10 of 23) of cases. Although the study was limited by the low response rate, use of the questionnaire provided a relatively simple means for assessing self-reported HIV exposure history.