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Opt-Out HIV Testing: Key Questions on Cost and Implementation

An Interview With Bernard M. Branson, M.D.

Summer 2011

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Advice on Adopting Opt-Out HIV Screening

Mascolini: Are US healthcare professionals adopting this strategy?

Branson: What I can say certainly is that professional organizations like the American College of Physicians and the American College of Obstetricians and Gynecologists have issued very similar recommendations to their members for HIV screening.

Percentage of persons aged 18-64 years who reported ever being tested for HIV (United States, 2001-2009), and percentage of late HIV diagnoses (AIDS diagnosis within 12 months of initial HIV diagnosis) (33 states, 2001-2007)

Percentage of persons aged 18-64 years who reported ever being tested for HIV (United States, 2001-2009), and percentage of late HIV diagnoses (AIDS diagnosis within 12 months of initial HIV diagnosis) (33 states, 2001-2007). (Reproduced from: Centers for Disease Control and Prevention. Vital signs: HIV testing and diagnosis among adults -- United States, 2001-2009. MMWR Morb Mortal Wkly Rep. 2010;59(47):1550-1555.13)

A CDC analysis showed that the proportion of Americans who said they'd been tested for HIV remained stable at 40% from 2001 to 2006, but then rose to 45% in the 3-year period from 2006 to 2009 (Figure).13 In 2009 a record 82.9 million adults in the United States reported having ever been tested for HIV infection. That represents an increase of 11.4 million people since the recommendations were issued in 2006. And we have numerous reports from groups that have initiated opt-out HIV screening programs.

All of this suggests that at least some healthcare professionals are adopting these recommendations. We always expected adoption and implementation to be incremental. We didn't think that everyone would just begin screening universally the year after the recommendations came out. But I do think we have evidence that they are being adopted.

Mascolini: If an institution decides to implement opt-out testing, what steps should it take to put this policy in place?

Branson: The most important first step is to get buy-in from all the stakeholders involved, both people in the institution and in the community. Also, for each institution, questions related to nursing, standing orders, and the laboratory, for example, must be addressed and solutions designed that are specific to the needs of that institution.

The CDC recommends that people receive information about HIV at the time they are tested, so there has to be a mechanism to deliver that information, whether with a pamphlet, a handout, or a video (Table 2). Similarly, people need to be advised that they have an opportunity to decline testing. Many institutions have done this with a separate information sheet that might say an HIV test is recommended as part of your care, here are the reasons for it, and if you don't want this test you should sign this and give it to one of the health care providers. I think those are necessary steps in the process of implementing opt-out testing.

Table 2. CDC Advice on Consent and Pretest Information1

Table 2. CDC Advice on Consent and Pretest Information

When CDC's recommendations came out, there was some confusion about whether CDC was recommending opt-out HIV testing or recommending rapid testing. Many places assumed that they have to do rapid point-of-care testing to implement these recommendations. Rapid testing is not part of the recommendation. Rapid testing may be important in settings where patients are unlikely to receive their results otherwise. But with the newer technologies available today, a conventional test can produce results in an hour or less, so it is not always necessary to use a point-of-care rapid test.

Mascolini: Are there other points you would like to add on any of these issues?

Branson: I think an important point is that programs that are implementing these recommendations are in fact identifying people who have undiagnosed HIV infection. The recommendations are having the desired outcome -- getting more people tested and getting more people linked into services where they can access treatment. And that treatment will have a substantial impact on improving their life expectancy and potentially in decreasing the likelihood that they will transmit HIV to others. I think the bottom line is that evidence accumulating since the recommendations came out indicates that they seem to be working: The number of persons who have been tested is going up, and the number whose HIV is diagnosed late is going down.


  1. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55:1-17. Accessed May 11, 2011.
  2. Fleishman JA, Yehia BR, Moore RD, Gebo KA; for the HIV Research Network. The economic burden of late entry into medical care for patients with HIV infection. Med Care. 2010;48:1071-1079.
  3. Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients who present late (CD4 <200 cells/microL) with HIV infection. HIV Med. 2004;5:93-98.
  4. Krentz HB, Gill J. Despite CD4 cell count rebound the higher initial costs of medical care for HIV-infected patients persist 5 years after presentation with CD4 cell counts less than 350 μl. AIDS. 2010;24:2750-2753.
  5. Hayden EC. 'Seek, test and treat' slows HIV. Nature. 2010;463:1006.
  6. Montaner JS, Lima VD, Barrios R, et al. Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study. Lancet. 2010;376: 532-539.
  7. White House Office of National AIDS Policy. National HIV/AIDS strategy for the United States. Washington, DC. July 13, 2010. Accessed May 11, 2011.
  8. Paltiel AD, Walensky RP, Schackman BR, et al. Expanded HIV screening in the United States: effect on clinical outcomes, HIV transmission, and costs. Ann Intern Med. 2006;145:797-806.
  9. Long EF, Brandeau ML, Owens DK. The cost-effectiveness and population outcomes of expanded HIV screening and antiretroviral treatment in the United States. Ann Intern Med. 2010;153:778-789.
  10. Yazdanpanah Y, Sloan CE, Charlois-Ou C, et al. Routine HIV screening in France: clinical impact and cost-effectiveness. PLoS One. 2010;5(10):e13132.
  11. Holtgrave DR. Costs and consequences of the US Centers for Disease Control and Prevention's recommendations for opt-out HIV testing. PLoS Med. 2007;4:e194. Accessed April 4, 2011.
  12. Branson B, Janssen R. Response to Holtgrave, DR "Cost and consequences of the US CDC's recommendations for opt-out HIV testing." PLoS Med. 31 March 2009. (Click on "Comments" tab after accessing Reference 11.)
  13. Centers for Disease Control and Prevention. Vital signs: HIV testing and diagnosis among adults -- United States, 2001-2009. MMWR Morb Mortal Wkly Rep. 2010;59(47):1550-1555. Accessed May 11, 2011.
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This article was provided by The Center for AIDS Information & Advocacy. It is a part of the publication Research Initiative/Treatment Action!. Visit CFA's website to find out more about their activities and publications.
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