Late HIV Diagnosis: Bad Medicine and Worse Public Health

I t is estimated that there are some 252,000–312,000 Americans living with HIV yet unaware that they carry this deadly virus [1]. Once they develop symptoms of HIV disease, most will be diagnosed. But by then, their immune systems will have experienced permanent damage, and thousands will have inadvertently infected their partners. One analysis reckons that annual HIV transmission rates in the United States are some 3.5 times higher among people with undiagnosed HIV infection compared to those who are diagnosed [2], due to the fact that knowledge of positive HIV serostatus is associated with substantial decreases in high-risk sexual behaviors among those so diagnosed [3]. Although HIV remains a very serious medical concern, with the advent of improved antiretroviral treatments it is no longer the hopeless condition it was in the early 1980s. Yet late diagnosis of HIV infection remains a problem in the US three decades after the syndrome was fi rst described, despite the substantial medical and public health benefi ts of early HIV diagnosis. In the US, about 40% of persons who were diagnosed with AIDS in 2005 had their fi rst positive HIV test less than 12 months before their AIDS diagnosis [4]—meaning that they were infected with HIV for years prior to their initial diagnosis. Nor can late HIV diagnosis be simplistically ascribed to lack of access to health care. A variety of studies have shown that failure to diagnose HIV in a timely manner occurs even among persons who have regular access to health care [5–7]. Arguably, addressing the persistent problem of late HIV diagnosis was the major driver in the recent push by the Centers for Disease Control and Prevention (CDC) for routine, opt-out testing in health-care settings, i.e., informing patients of the intent to perform HIV testing and inferring consent unless the patient declines [8]. Citing the time constraints of risk-assessment and counseling, CDC's 2006 guidelines also note that " prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening in health care settings " [8]. In a new study published in PLoS Medicine, David Holtgrave estimates the overall costs of CDC's routine HIV testing recommendations using standard methods of scenario and cost-effectiveness analysis [9]. His fi ndings are provocative: in his scenarios, targeted HIV counseling and testing performed better than opt-out testing in terms of expense, number of newly identifi ed patients, and prevention …