- Urging a major shift in U.S. policy, some health experts
are recommending that virtually all Americans be tested routinely for the
AIDS virus, much as they are for cancer and other diseases.
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- Since the early years of the AIDS epidemic in the 1980s,
the government has recommended screening only in big cities, where AIDS
rates are high, and among members of high-risk groups, such as gay men
and drug addicts.
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- But two large, federally funded studies found that the
cost of routinely testing and treating nearly all adults would be outweighed
by a reduction in new infections and the opportunity to start patients
on drug cocktails early, when they work best.
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- "Given the availability of effective therapy and
preventive measures, it is possible to improve care and perhaps influence
the course of the epidemic through widespread, effective and cost-effective
screening," Dr. Samuel A. Bozzette wrote in an editorial accompanying
the studies, which appear in Thursday's New England Journal of Medicine.
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- A failure to institute such screening at doctors' offices
and clinics would be "a critical disservice" to patients with
the AIDS virus and "the future health of the nation," wrote Bozzette,
who is from the University of California at San Diego and the Rand Corp.
think tank in Santa Monica, Calif.
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- Dr. Robert Janssen, director of HIV-AIDS prevention at
the Centers for Disease Control and Prevention, said the CDC will re-evaluate
its guidelines over the next two years, and will consider the study's findings
as well as the availability of new, rapid HIV tests that produce results
in a half-hour instead of the usual week or two.
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- Who would bear the cost of expanded testing - and the
cost of the treatment, which runs to at least $15,000 a year - remains
a sticky question amid government cutbacks in health-care funding. However,
Janssen said the studies' findings could lead to some private insurers
to encourage more HIV testing.
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- One of the studies, by researchers at Duke and Stanford
universities and the Veterans Affairs Palo Alto Health Care System, estimated
that routine one-time testing of everyone would cut new infections each
year by just over 20 percent, and that every HIV-infected patient identified
would gain an average of 1 1/2 years of life.
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- The other study, by Yale and Harvard researchers, found
that testing people every three to five years would be cost-effective for
all but the lowest-risk people, such as those who are celibate or are in
monogamous heterosexual relationships. And even for those people, one-time
testing was found to be cost-effective.
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- Nationwide, about 40,000 new HIV infections occur each
year. An estimated 950,000 people are infected with the virus, but about
280,000 of them don't know it.
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- CDC guidelines recommend routine tests wherever the prevalence
of HIV infection is more than 1 percent - basically, cities and some densely
populated suburbs.
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- "If you need proof of the fact that it's not working,
look at all the people who have slipped through the cracks - 280,000,"
said A. David Paltiel of the Yale School of Medicine's division of health
policy, lead author of the second study.
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- The VA-funded study found that in areas where about 1
in 100 patients has undiagnosed HIV - what the CDC calls high-risk settings
- widespread testing would cost about $15,100 for each year of good health
gained by people diagnosed with the virus, counting the benefits to their
sexual partners.
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- Even in areas with an undiagnosed HIV infection rate
of only 1 in 2,000 - the rate in the general population - each healthy
year gained by newly diagnosed HIV patients and their partners would still
cost less than $50,000. That is the threshold at which health economists
generally consider treatments to be cost-effective.
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- Paltiel noted the two groups of researchers had very
similar cost-benefit results, even though they used different computer
models.
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- "The cost-benefit to individuals and society is
worth" widespread screening, said Dr. Lawrence Deyton, chief of public
health in the Department of Veterans Affairs, which provides medical care
to about 5 million veterans.
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- In light of the findings, he said the VA is going to
urge more patients to get tested.
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- "We're going to take the ball and run with it,"
Deyton said.
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