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Editor's Correspondence |

What Is a Modest Public Health Impact?

Yazdan Yazdanpanah, MD, PhD; Rochelle P. Walensky, MD, MSc; Willy Rozenbaum, MD, PhD; Patrick Yeni, MD, PhD; A. David Paltiel, PhD
Arch Intern Med. 2012;172(6):521-522. doi:10.1001/archinternmed.2011.1876.
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d’Almeida et al1 evaluated routine human immunodeficiency virus (HIV) screening in 29 emergency departments (EDs). We believe that the results of this study are open to very different interpretations and conclusions:

  • The authors characterize the observed prevalence of newly diagnosed infections (0.14%) as “low.” Applying this value to all persons aged 18 to 64 years in France translates to 56 000 undetected HIV infections. To put that number in perspective, estimates of 50 000 undetected cases were sufficiently alarming to provoke recommendations on routine HIV screening. Similarly, studies from the United States and France demonstrate that routine HIV screening remains cost-effective at prevalences as low as 0.10%.2

  • The authors recommend targeted screening because 17 of 18 cases identified in their study were drawn from “high-risk” populations. Of the newly notified cases in the French national HIV surveillance database in 2009, 28% are heterosexuals of non–sub-Saharan–African origin. Further evidence shows that these “lower-risk” cases are diagnosed as having more advanced HIV illness and that risk-based targeted testing has failed such patients.3

  • The authors argue that many high-risk cases identified would likely have been identified anyway via diagnostic testing. This contradicts the growing body of literature on the barriers to HIV screening and missed opportunities to test for HIV among high-risk candidates. A number of studies demonstrate that it is hard to implement targeted screening: health care providers lack time and expertise to conduct risk evaluation; patients are inaccurate in reporting their risk status; and targeting injects an anxiety-ridden, stigmatizing tone into the patient-provider discussion that results in low testing rates.4

  • The authors claim that ED-based detection failed to reveal HIV at earlier stages. They based their assessment on 12 detected cases with available CD4 cell counts. No doubt, these patients seen in an ED setting were sick. But the question of interest is whether they are diagnosed earlier when compared with a targeted screening program. Nothing in the study by d’Almeida et al1 sheds light on that question. Haukoos et al5 compared targeting with routine ED screening. They too reported sick patients, but median CD4 cell counts among cases diagnosed via nontargeted screening (69/μL [interquartile range, 17-430/μL]) were significantly higher than among cases diagnosed via targeted screening (13/μL [interquartile range, 11-15/μL]; P = .02).5

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