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LETTERS: Anna Maria Geretti, Sara Madge, Marcus Posner, Geoff Dusheiko, and Michael Jacobs Undiagnosed HIV infection in patients with viral hepatitis BMJ 2008; 336: 1451-b-1452-b [Full text]

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Opt-out testing not necessarily the answer

James R Hanison, William Welfare   (16 July 2008)

Opt-out testing not necessarily the answer 16 July 2008
James R Hanison, Foundation Year 2 Doctor Greater Manchester Health Protection Unit, Floor 7b Sentinel House, Albert St, Manchester M30 0NJ, William Welfare Send response to journal: Re: Opt-out testing not necessarily the answer	Letter to editor Geretti et al. raise an important issue in their retrospective seroprevalence study of patients attending a viral hepatitis referral unit.[1] The study highlights how the current clinician directed testing did not detect all cases of HIV in their patient group and raises interesting questions with regards to whether an opt-out HIV testing policy would be cost effective for patients with viral hepatitis. Only 12 clinician initiated tests for HIV were performed during the study period, it is unknown whether the other patients in this trial had previously been tested for HIV and whether the clinicians were aware of these data, so it is difficult to comment on this. The issue of cost effectiveness of HIV testing is also raised in this study. Based on research from the US as cited in the article,[2] it is thought to be cost effective to initiate routine HIV testing in all health care settings if the prevalence of undiagnosed HIV exceeds 0.05-0.1%. This study cites total prevalence of HIV in the study group (including cases diagnosed by the clinicians); the total number of undiagnosed cases is 2 out of 266, i.e. 0.75% (95% CI –0.29-1.79%). Even if the cost effectiveness analysis (CEA) is transferable to the UK (which is unclear), the rate of undiagnosed HIV does not necessarily fit the cost effectiveness threshold. This study highlights the fact that the current policy of clinician directed HIV testing in this cohort of patients fails to detect half of patients with HIV and a new approach needs to be developed to improve detection rates. Currently it is unclear whether an opt-out policy in all health care settings, in some clinics or better targeting of clinician directed tests is needed. Research such as by Geretti et al makes an important contribution to this debate, but more work, including UK CEA, is needed. James Hanison, foundation year 2 doctor, William Welfare, specialist registrar in public health medicine. (jamesrhanison@yahoo.co.uk) This letter is written in response to a journal club meeting at the Greater Manchester Health Protection Unit, Manchester M30 0NJ on 08/07/07 References [1] Geretti AM, Madge S, Posner M, Dusheiko G, Jacobs M. Undiagnosed HIV infection in patients with viral hepatitis. BMJ 2008 336(7659): 1451- 1452 [2] Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, Clark JE; Centers for Disease Control and Prevention (CDC). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recommendations and Reports 2006 55(RR-14): 1-17 Competing interests: None declared