Many People Disregard Advice to Get HIV Tests, Epidemic of Cancers Feared With HIV Link

February 4, 2009

Many clinicians are not screening patients for HIV as a routine part of health care because they perceive testing takes too much time and because many insurers are reluctant to reimburse for the procedure.

Many People Disregard Advice to Get HIV Tests
Many clinicians are not screening patients for HIV as a routine part of health care because they perceive testing takes too much time and because many insurers are reluctant to reimburse for the procedure. An oral HIV test and possible confirmatory testing can cost a patient $80 to $120, attendees were told at the 2008 National Summit on HIV Diagnosis, Prevention and Access to Care, which was held in Arlington, Va, in November (Brown D. Washington Post. November 21, 2008).

“Reimbursement is a major barrier to routine testing,” said Dr Kevin Fenton, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. Two years ago, the CDC recommended universal, voluntary HIV screening be offered on an “opt-out” basis for patients aged 13 to 64 years in health care settings.

However, only about 5% of seriously ill patients are being routinely screened for HIV in hospital emergency departments (EDs), said Veronica Miller, director of the Forum for Collaborative HIV Research.

Just 0.8% of ED patients were HIV-positive in oral screenings at George Washington University Medical Center, much lower than the district’s estimated 5% prevalence. About half of the patients from Washington’s wealthiest ward opted not to test, compared with one-third of those from the poorest ward. Researchers suggested that HIV prevalence may have been higher among the opt-outs.

In Philadelphia’s Hahnemann University Hospital, trained counselors offered rapid HIV tests to ED patients during sessions lasting just more than 5 minutes. Among the patients, 83% consented to testing: about half were women; 80% were black; and the average age was 36 years. Just 0.7% were HIV-positive.

In Chicago’s John H. Stroger Jr. Hospital, slightly fewer than 1% of about 2000 ED patients who were offered testing were HIV-positive. However, more than 90% of the HIV-positive patients already had CD4+ cell counts of below 200/µL. On average, the patients had visited the hospital’s ED 3 times during the 2 years before their simultaneous HIV/AIDS diagnoses. [CDC HIV/Hepatitis/STD/TB Prevention News Update, Monday, December 1, 2008]

Epidemic of Cancers Feared With HIV Link
People with HIV are at a much greater risk for developing certain cancers-including of the lung, liver, head, and neck-than the general population, according to research reported at a medical conference in National Harbor, Md (Chicago Tribune. November 19, 2008; Desmon S. Baltimore Sun. November 19, 2008). “We’re seeing people we have treated successfully for HIV at much higher risk” for cancer, said Dr Kevin Cullen, director of the University of Maryland’s Greenebaum Cancer Center.

The research, presented by Johns Hopkins epidemiologist Meredith Shiels at the 7th Annual American Association for Cancer Research International Conference on Frontiers in Cancer Prevention Research, found that people with HIV infection are twice as likely to develop several cancers not previously linked to the virus. Earlier studies have found that the risk of certain cancers is up to 10 times higher for people with HIV infection. Some of the cancers seen most commonly among HIV-infected patients are those known to have viral causes: anal, head, and neck cancers, which have been linked to human papillomavirus, and liver cancer, which can be caused by hepatitis.

Various hypotheses have been offered for the HIV-cancer connection: Thanks to improved drug therapy, more HIV-infected patients are living longer. Patients’ immune systems may be weakened by the virus or damaged by antiretrovirals; indeed, one researcher has questioned whether the drugs themselves may be carcinogenic. Some people with HIV infection may also engage in more high-risk behaviors. “We’re really at the first stages of systematically looking at the epidemic and fully looking at cancer,” said Dr William Blattner, associate director of the University of Maryland’s Institute of Human Virology. “The unusual observation is the cancers are occurring at a much younger age.”

Dr Malcolm Brock, a thoracic surgeon at Johns Hopkins, said HIV-infected patients have 3 to 5 times the lung cancer risk of the general population, a phenomenon being studied by researchers from Hopkins and the National Cancer Institute. [CDC HIV/Hepatitis/STD/TB Prevention News Update, Wednesday, November 19, 2008]

Misconceptions “Still Cause AIDS Stigma” in China
A UNAIDS (Joint UN Programme on HIV/AIDS) official said widely held misconceptions about AIDS in China are making it more difficult to garner public support for those with the disease, despite years of educational efforts. In a recent survey of more than 6000 Chinese, 80% correctly knew that HIV can be transmitted through unprotected sex and contaminated syringes. But 30% did not know how to properly use a condom, including 57.2% of participants aged 15 to 24 years (Xinhua. November 18, 2008).

About half viewed HIV/AIDS as a serious problem in China, although 88% rated their personal risk of the disease at zero. Just as worrisome, 48% believed HIV could be transmitted by a mosquito bite, and 18% thought the virus could be spread through an infected person’s cough or sneeze. About 16% thought HIV could be spread by sharing a cup or eating with someone who is HIV-positive.

These myths undermine efforts to work against disease stigma and discrimination, said Bernhard Schwartlander, UNAIDS China country coordinator. Nearly 65% of respondents said they would not want to live with someone who has HIV/AIDS; 47.8% would not want to eat with an HIV-positive person; 41.3% said they would be unwilling to work with an infected colleague; and almost 16% said they would break off contact with an infected relative.

“These data are really a cause for concern,” Schwartlander said. “We see that there are still many misconceptions around AIDS among the population, which contribute to stigma and discrimination,” he said. “Though people know that HIV can be transmitted through unprotected sex many still do not protect themselves with a condom when engaging in risky behavior.”

The survey was conducted by the Global Business Coalition on HIV/AIDS, TB and Malaria, the China HIV/AIDS Media Partnership, Renmin University, and UNAIDS. Respondents were interviewed in Beijing, Shanghai, Shenzhen, Wuhan, Zhengzhou, and Kunming. [CDC HIV/Hepatitis/STD/TB Prevention News Update, Tuesday, November 18, 2008]

CD4 Monitoring Cost-Effective in Sub-Saharan Africa
A model was developed to compare the costs and benefits of 3 types of HIV monitoring strategies: symptom-based strategies; CD4-based strategies; and CD4 counts plus viral load strategies for initiating, switching, and stopping antiretroviral therapy. A cost-effectiveness analysis was performed using clinical and cost data from southern Africa. All assumptions were tested in sensitivity analyses. The results of the study by Bendavid and colleagues were recently published in the Archives of Internal Medicine (Bendavid E, Young SD, Katzenstein DA, et al. Cost-effectiveness of HIV monitoring strategies in resource-limited settings: a southern African analysis. Arch Intern Med. 2008;168:1910-1918).

Compared with the symptom-based approaches, monitoring CD4 counts at 6-month intervals and initiating treatment at a threshold of 200/µL was associated with a gain in life expectancy of 6.5 months (61.9 months vs 68.4 months) and a discounted lifetime cost savings of $464 per person ($4069 vs $3605, discounted 2007 US dollars). CD4-based strategies that started treatment at the higher threshold of 350/µL provided an additional gain in life expectancy of 5.3 months at a cost-effectiveness of $107 per life-year gained compared with the strategy that started treatment at a threshold of 200/µL. Monitoring viral loads with CD4 was more costly than monitoring CD4 counts alone, added 2.0 months of life, and had an incremental cost-effectiveness ratio of $5414 per life-year gained relative to monitoring of CD4 counts alone. Sensitivity analyses showed that the cost savings from CD4 count monitoring, compared with the symptom-based approaches, was sensitive to cost of inpatient care, and the cost-effectiveness of viral load monitoring was influenced by the per-test costs and rates of virological failure.

“Use of CD4 monitoring and early initiation of HAART in southern Africa provides large health benefits relative to symptom-based approaches for HAART management,” the authors concluded. “In southern African countries with relatively high costs of hospitalization, CD4 monitoring would likely reduce total health care expenditures. The cost-effectiveness of viral load monitoring depends on test prices and rates of virologic failure.” [CDC HIV/Hepatitis/STD/TB Prevention News Update, Tuesday, October 7, 2008]