Routine HIV testing at the point of care in an OPD in Durban, South Africa identified nearly 5 times as many new cases per week as HIV testing by physician referral to an adjacent hospital-affiliated VCT site (39 vs. 8 new cases per week). During the standard of care period, only 31.5% of referred patients were actually tested at the VCT site in the subsequent 4 weeks. During the intervention period, almost half of patients offered HIV testing in the OPD accepted testing through the routine testing program and more than 32% of those tested during the routine testing program were found to be HIV infected. The median CD4 cell counts for those tested based on physician referral and those tested by routine testing were not significantly different, suggesting that routine testing in this setting did not find patients at an earlier stage of illness.
The South African government has made major strides in expanding access to VCT sites as part of its national HIV operational plan.4,26
This study suggests that VCT sites fail to capture a large number of HIV-infected patients who are making contact with the health system and are not being referred for testing by physicians or are not following through with the referral.
Early diagnosis and entry into care in developed countries are associated with improved prognosis and survival27,28
and may prove essential to stabilizing South Africa’s HIV epidemic and its impact on the socioeconomic situation. In addition, awareness of HIV status has been shown in Zambia, Kenya, Tanzania, and Trinidad to reduce high -risk sexual behaviors in serodiscordant couples,29,30
and may thereby lead to improved epidemic control.
Provision of VCT centers, where patients can seek out an HIV test, is helpful for those who are self-motivated to get tested for HIV infection. VCT sites in South Africa are often physically separate from hospitals or clinics or housed in areas remote from patient care. Pilot programs integrating VCT into rural primary health facilities in Kenya and South Africa have been proposed and implemented as a means of improving access to testing, but these programs remain underused, despite the increasing availability of ARV medication.9,31
Routine HIV testing to increase knowledge of serostatus has been advocated by policy makers in Africa, particularly now that ARV therapy has become more widely available.32–34
The notion of offering HIV testing as part of routine medical care has been extended further by Botswana, where the government promotes “opt out” HIV testing. In this approach, all patients are tested at point of contact with the medical community unless they specifically decline, without the extensive counseling typical of VCT.35,36
This policy has been successfully implemented in 4 prenatal centers in Botswana, with improvement of testing uptake rates from 76% to 92%.24
Lesotho, with the third highest HIV infection rate in the world, has announced plans to offer testing to all 1.9 million citizens in an effort to curb stigma.37
The current study supports the position that HIV testing offered routinely to all adults in the health care setting rather than testing based exclusively on physician assessment or pregnancy status significantly improves case finding. This acceptance may reflect a normalization of testing, because all patients are offered the test regardless of age, ethnicity, or chief complaint as part of the package of care in the OPD. Although more patients tested by means of routine HIV testing are found to be HIV-negative compared with physician-based VCT referral because of a lower pretest probability of disease, the high HIV prevalence justifies expanded testing; indeed, the counseling session offers an opportunity to educate patients and to reinforce prevention messages.7
The cost per patient tested was the same during the standard of care and the routine testing periods; although the cost per HIV case identified was twice as high during the routine testing study, it was still less than $25 per HIV case identified. In the United States, where HIV is an order of magnitude less prevalent than in South Africa, the cost of HIV testing is significantly lower than the cost of care and treatment of patients once they are identified.20,38
As ARV treatment with CD4 cell count and viral load monitoring becomes available in South Africa, the cost of HIV care is likely to be driven by treatment costs rather than by the relatively low cost of offering routine testing in this setting as well. Cost-effectiveness analyses have demonstrated that ARV therapy is cost-effective in resource-limited countries;39
although further studies are needed, the current study suggests that routine testing is also likely to prove cost-effective.
This study has several limitations. The patients routinely tested in the OPD were typically healthier and ambulatory patients on the urgent side of the department (as opposed to the “emergent” side), who could independently enter a private counseling room. As a result, we did not reach sicker patients, possibly underestimating the overall prevalence of disease and failing to diagnose those who could benefit most immediately from ARV treatment. Older chronically ill patients who were repeat visitors make up a significant minority of patients in the OPD, which may limit the number of new HIV cases that can be identified at McCord Hospital in the long term. Expanding the routine testing effort to the inpatient setting, where more acutely ill patients are located, might help to overcome some of these limitations.
In addition, McCord Hospital is a semiprivate hospital; results from this study may not be generalizable to the public sector, where many HIV-infected patients seek care free of charge and HIV prevalence is likely to be higher. Patients referred from the OPD for HIV testing during the standard of care period were charged 25 Rand (~$3.60 in 2005 US dollars) for an HIV test; during the routine testing intervention, patients were not charged for HIV testing. We do not know the degree to which the removal of the charge influenced patients’ decision to test; however, the charge for the visit to the OPD was 140 Rand (~$19.26 in 2005 US dollars); thus, the HIV test was only a small additional cost. In a large South African household survey, the most frequently cited reasons for not having tested for HIV related to confidentiality and not being at risk.7
The routine testing intervention required a team of dedicated HIV counseling staff to accommodate the high volume of patients seen in the OPD; this level of staff investment may not be feasible in all health care settings. In light of current WHO and PEPFAR initiatives to improve identification of HIV-infected individuals in areas where appropriate linkage to care is available, however, a commitment to testing is warranted.23,40
Routine HIV testing can more than quadruple HIV case identification in outpatient settings. Integrating HIV testing into routine health care in South Africa has the potential to improve HIV case finding by minimizing logistic barriers to testing and normalizing the diagnosis and treatment of HIV infection. Early diagnosis of HIV-infected individuals and linkage to care are critical to improving individual health and to secondary prevention efforts aimed at slowing the HIV epidemic. New approaches to facilitate HIV testing in South Africa and other countries with high prevalence, where access to HIV care is increasing, are of paramount importance for improving individual patient outcomes and public health.