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Contact: Andrew Hyde
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Public Library of Science

Controversial US strategy on HIV testing; ethnic disparities in diabetes care persist

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CDC’s recommended opt-out HIV testing strategy may not perform as well as more targeted counseling and testing

The US Centers for Disease Control and Prevention (CDC) recently advised health professionals to offer every patient aged 13-64 years “opt-out” HIV testing (i.e. testing without the need for risk assessment and counseling). But a new study by Professor David Holtgrave (Johns Hopkins Bloomberg School of Public Health) in this week’s PLoS Medicine finds that testing only those people at high risk of HIV, rather than offering everybody a test, would be a better strategy for diagnosing HIV infections and for helping to stop the spread of the virus.

About a quarter of a million people in the US do not realize they are infected with HIV. Because they are unaware of their infection, they don’t get the medicines they need to stay healthy, and they may also be transmitting HIV to others unwittingly. The CDC hopes that its new recommendations on opt-out testing will allow health professionals to reach more of these people.

In order to assess the potential costs and public health impact of the CDC recommendations, Professor Holtgrave used two standard research techniques (cost effectiveness analysis and scenario analysis) to compare opt-out testing with “targeted counseling and testing.” In targeted testing, health professionals focus their efforts on those who are at increased risk of being HIV positive (e.g. patients attending sexual health clinics, drug treatment centers, or clinics in prisons). Such patients are offered counseling before the test, to assess their actual risk of HIV and to discuss what would happen in the event that the HIV test comes back positive. During counseling, people are also given advice on steps they can take to stay HIV negative if their test comes back negative, and to prevent infecting others if their test comes back positive.

According to Professor Holtgrave’s analysis, opt-out testing might reach 23% of those people who are currently unaware that they are HIV positive.The program might also prevent 9% of the 40,000 new HIV infections that occur each year in the US. The cost of averting one new infection would be US$237,149. In contrast, targeted counseling and testing might identify about 75% of people in the US now unaware they are living with HIV infection, and prevent about 36% of the new HIV infections. The cost of averting one new infection would be US$59,383.

Even when the author changed several assumptions in his analysis (e.g., assumptions about levels of HIV infection or the effectiveness of counseling), he found that targeted counseling and testing still performed better (so the results are ‘‘robust’’ across a variety of such assumptions).

The author concludes that “abandoning client-centered counseling has real public health consequences in terms of HIV infections that could have been averted.”

A related Perspective article that discusses Professor Holtgrave’s study is at http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040200.

Citation: Holtgrave DR (2007) Costs and consequences of the US Centers for Disease Control and Prevention’s recommendations for opt-out HIV testing. PLoS Med 4(6): e194.

In your article, please link to this URL, which will provide access to the published paper: http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040194

Press-only preview of the article:

http://www.plos.org/press/plme-04-06-holtgrave.pdf

Related image for press use:http://www.plos.org/press/plme-04-06-holtgrave.jpg

Caption: HIV Counseling and Testing Strategies

Contact:

David Holtgrave
Johns Hopkins Bloomberg School of Public Health
Department of Health, Behavior and Society
624 N Broadway
Baltimore, MD 21205
United States of America
+1 410-502-4076
dholtgrave@jhsph.edu

Related PLoS Medicine Perspective:

Citation: Valdiserri RO (2007) Late HIV diagnosis: Bad medicine and worse public health. PLoS Med 4(6): e200

In your article, please link to this URL, which will provide access to the published paper:http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040200

Press-only preview of the article: http://www.plos.org/press/plme-04-06-valdiserri.pdf


Diabetes care improves after UK reforms of general practice, but ethnic disparities remain

Research published in PLoS Medicine examines the impact of the UK government’s new contract with general practitioners (family doctors) on the care of people with diabetes. The research, conducted in Wandsworth in London, found that improvements had occurred, but black people of Caribbean origin were not benefiting to the extent of other ethnic groups. This is despite the fact that reducing differences in the quality of health care provided to different patient groups was one of the aims of the reforms.

In the UK, as in many countries, people from ethnic minorities are more likely to develop diabetes than the majority population and their condition is typically not so well “managed”—i.e., it becomes more severe more rapidly and there are more complications. Addressing the gap between ethnic groups was one goal in the major health reforms launched by the government, which included the introduction of a “pay-for-performance” contract between the health service and general practitioners (GPs). It was agreed in 2004 that GPs would receive increases to their income that would depend on how well they were judged to be performing. The effectiveness of diabetes care, for which there are defined “treatment targets”, is one of the areas in which GPs' performance is assessed.

Wandsworth was chosen by the researchers, who are based at Imperial College, London and at the University of Leicester, as it is a very ethnically diverse area of London. The researchers used GPs' electronic records on the 4,200 people with diabetes registered in Wandsworth. Overall, they found that more patients met their treatment targets after the introduction of pay-for-performance management than were doing so before. All ethnic groups seemed to have benefited, but the black Caribbean group did not benefit as much as the other groups; the number of these patients who met the targets did improve, but the gap between them and patients with diabetes from other ethnic groups remained about the same.

The UK’s use of pay-for-performance in general practice is regarded internationally as a very bold step. As other countries are also considering moving in this direction, the lessons from the study will be relevant in many other parts of the world.

In a Perspective article discussing the new study, Katie Coleman and Richard Hamblin (Center for Health Studies, Group Health Cooperative, Seattle, USA) say that the study results show that "pay for performance alone may not be able to drive equitable improvement in health care quality."

Citation: Millett C, Gray J, Saxena S, Netuveli G, Khunti K, et al. (2007) Ethnic disparities in diabetes management and pay-forperformance in the UK: The Wandsworth Prospective Diabetes Study. PLoS Med 4(6): e191.

In your article, please link to this URL, which will provide access to the published article: http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040191

Press-only preview of the article: http://www.plos.org/press/plme-04-06-millett.pdf

Contact:

Christopher Millett
Imperial College
Primary Care and Social Medicine
3rd Floor, Reynolds Building
St Dunstan's Road
London, London W6 8RP
United Kingdom
+44 20 7594 0817
c.millett@imperial.ac.uk

Related PLoS Medicine Perspective:

Citation: Coleman K, Hamblin R (2007) Can pay-for-performance improve quality and reduce health disparities" PLoS Med 4(6): e216.

In your article, please link to this URL, which will provide access to the published paper: http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040216

Press-only preview of the article: http://www.plos.org/press/plme-04-06-coleman.pdf

Contact:

Catherine Coleman
Group Health Cooperative
MacColl Institute for Healthcare Innovation
Center for Health Studies
Seattle, WA 98101
United States of America
coleman.cf@ghc.org


Poor performance of commercial antibody tests for TB

Blood-based antibody detection tests for tuberculosis (TB) have come under the spotlight in a research article published in PLoS Medicine. The authors, based in North America and Europe, conducted a “systematic review and meta-analysis” of studies that have been conducted on the accuracy of the tests, and have concluded that they do not perform well in comparison to standard methods. Many of the studies have been poorly conducted, and there is a lack of information on how the tests perform with children and people who are infected with HIV.

The standard test for TB (the sputum-smear test) has limitations. It is not particularly good at identifying active TB disease in children or people who are HIV-positive. It is also not very sensitive; in other words many people who have active TB disease may not give a positive reading. Therefore, there is an urgent need to develop and evaluate new tests. These tests would have to be cheap, as the countries with the highest rates of TB are in the developing world.

Many companies have developed tests intended to detect the presence of antibodies against TB in the patient’s blood. These tests are now being strongly promoted for use in developing countries. However, the authors of the PLoS Medicine article have concluded that, “…published data on commercial antibody detection tests produce inconsistent estimates of accuracy, and none of the assays performs well enough to replace sputum-smear microscopy. These tests thus have little or no role to play in the diagnosis of pulmonary TB at the present time”. (Efforts are under way to develop advanced versions of antibody and antigen detection tests, using new technologies. More research to evaluate these newer tests is needed.)

Citation: Steingart KR, Henry M, Laal S, Hopewell PC, Ramsay A, et al. (2007) Commercial serological antibody detection tests for the diagnosis of pulmonary tuberculosis: A systematic review. PLoS Med 4(6): e202.

In your article, please link to this URL, which will provide access to the published paper: http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040202

Press-only preview of the article: http://www.plos.org/press/plme-04-06-pai.pdf

Related image for press use:

http://www.plos.org/press/plme-04-06-pai.jpg

Caption: Commercial antibody tests for TB produce inconsistent estimates of accuracy, and have no role in the diagnosis of pulmonary TB

Contact:

Michael Bourguignon
University and Media Relations Office
McGill University
Montreal
Canada
+1 514.398.8305
+1 514.398.7364
michael.bourguignon@mcgill.ca


Longitudinal assessment of an ELISPOT test for Mycobacterium tuberculosis infection

Philip Hill and colleagues report that both ELISPOT conversion and reversion occur after Mycobacterium tuberculosis exposure in an endemic country and that the ELISPOT results agree poorly with results from the tuberculin skin test.

Citation: Hill PC, Brookes RH, Fox A, Jackson-Sillah D, Jeffries DJ, et al. (2007) Longitudinal assessment of an ELISPOT test for Mycobacterium tuberculosis infection. PLoS Med 4(6): e192.

In your article, please link to this URL, which will provide access to the published paper: http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040192

Press-only preview of the article: http://www.plos.org/press/plme-04-06-hill.pdf

Contact:

Philip Hill
MRC Laboratories
Bacterial Diseases Programme
MRC laboratories Fajara Atlantic Boulevard
PO Box 273
Banjul
Gambia
+220 449 4072
+220 449 6513 (fax)
phill@mrc.gm

Related PLoS Medicine Perspective:

Citation: Pai M, O’Brien R (2007) Serial testing for tuberculosis: Can we make sense of T cell assay conversions and reversions" PLoS Med 4(6): e208.

In your article, please link to this URL, which will provide access to the published paper: http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040208

Press-ony preview of the article: http://www.plos.org/press/plme-04-06-pai-perspective.pdf

Contact:

Michael Bourguignon
University and Media Relations Office
McGill University
Montreal
Canada
+1 514.398.8305
+1 514.398.7364
michael.bourguignon@mcgill.ca

###

About PLoS Medicine:

PLoS Medicine is an open access, freely available international medical journal. It publishes original research that enhances our understanding of human health and disease, together with commentary and analysis of important global health issues. For more information, visit http://www.plosmedicine.org

About the Public Library of Science:

The Public Library of Science (PLoS) is a non-profit organization of scientists and physicians committed to making the world's scientific and medical literature a freely available public resource. For more information, visit http://www.plos.org



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