In a perspective article in the March 7, 2013 issue of The New England Journal of Medicine, Erika G. Martin, assistant professor of public administration and policy at Rockefeller College of Public Affairs & Policy at the University at Albany, and fellow at the Rockefeller Institute of Government, discusses proposed changes in HIV-testing guidelines by the U.S. Preventive Services Task Force (USPSTF).
The article is co-authored by Bruce R. Schackman, associate professor of public health and chief of the Division of Health Policy at Weill Cornell Medical College. Martin and Schackman address the broad impact the changes will have on the health care of HIV-infected patients. "Updating the HIV-Testing Guidelines — A Modest Change with Major Consequences," argues that changes to proposed guidelines, including assigning a grade "A" recommendation to screening for HIV in the general population 15 to 65 years of age, will have significant implications for the way HIV testing is financed, largely due to the implementation of the Affordable Care Act. View a news release from the University at Albany that provides more information about Martin and Shackman's article.
Recently Dr. Martin discussed the roles of the various organizations involved in making recommendations related to preventive medicine and public health, and the impact of national health reform on HIV testing. A transcript of the interview with Dr. Martin follows:
What is the role of the U.S. Preventive Services Task Force? And how does it differ from the Centers for Disease Control and Prevention (CDC)? Can both bodies make recommendations?
Dr. Martin: The USPSTF is an independent group of experts in preventive medicine and primary care. It issues national recommendations about screening, counseling services, and medications related to preventive medicine. Although the USPSTF is supported by the Agency for Healthcare Research and Quality, an agency within the U.S. Department of Health and Human Services (HHS), the USPSTF makes independent decisions that do not have to be approved by AHRQ or HHS. The CDC is also an agency within HHS that works with state departments of health to monitor health trends, promote public health, and conduct research on public health prevention strategies. The CDC can also make recommendations related to preventive services.
What are the USPSTF and CDC recommendations on HIV testing?
Dr. Martin: In 2006, the CDC recommended that HIV testing be part of routine medical care, rather than being limited to high-risk populations. They advocated for all adults and adolescents from 13 to 64 years of age to be tested, and that special consent and pre-test counseling processes be eliminated. The USPSTF's draft recommendations give an "A" grade to HIV testing in the general population.
How does the USPSTF's new recommendation differ from its last recommendation?
Dr. Martin: In 2005, the USPSTF gave an "A" grade to HIV testing among adults and adolescents at increased risk for HIV infection, and also among pregnant women. It gave a "C" grade to routine testing among adults and adolescents who are not at increased risk. The new draft recommendation gives an "A" grade to everyone aged 15 to 65, regardless of risk. For HIV testing, "high risk" would refer to behaviors such as injection drug use or else living in a high-prevalence area such as the Bronx or the District of Columbia.
Can you explain the letter grades?
Dr. Martin: The USPSTF assigns letter grades to each preventive service, based on the strength of the evidence related to the intervention's harms and benefits. There are five letter grades. The USPSTF recommends that services with an "A" or "B" grade be offered in clinical practice, because there is reasonable certainty that the net benefit is moderate to substantial. A "C" grade means that the USPST is not making a recommendation for or against the use of the service. A "D" grade is assigned when it is likely that the service has no net benefit or else the harms outweigh the benefits. The USPSTF discourages that services with a "D" grade be used in clinical practice. Finally, an "I statement" means that the current evidence is insufficient to fully evaluate the benefits and harms.
Who accepts the CDC and USPSTF recommendations on preventive services? Do the recommendations have the force of a mandate?
Dr. Martin: States and local jurisdictions are not required to follow the CDC's recommendations on which preventive services to offer. In the case of HIV testing, many states had laws related to HIV testing that were not consistent with the CDC's recommendations. However, the CDC can encourage HIV testing by providing funds to state and local health departments to test their residents. The USPSTF recommendations also do not have the force of a mandate. However, many private health insurance plans use the USPSTF recommendations as a guide for what services to reimburse. Medicaid and Medicare plans also tend to follow the USPSTF recommendations. This means that preventive services that are recommended by the USPSTF are likely to be reimbursed by public and private payers.
Your article discusses the Affordable Care Act. How does national health reform relate to this issue?
Dr. Martin: As part of the Affordable Care Act, private insurance and Medicare plans are already required to offer all preventive services with an "A" or "B" recommendation without requiring out-of-pocket costs from patients. Starting this year, there will be additional incentives for state Medicaid programs to offer these preventive services to clients without out-of-pocket costs. That means that if the draft recommendations are adopted, all Americans with public or private insurance should be able to get an HIV test without paying for it.
You mention that these are draft recommendations. What does that mean and when will the guidelines be finalized?
Dr. Martin: The USPSTF first issues draft recommendations with a public comment period. The public comment period ended on December 20, 2012. The final recommendations generally take about three to six months to become finalized after the public comment period, so we are likely to see the final recommendations issued this spring or summer.
What kind of evidence is considered in the recommendations?
Dr. Martin: The USPSTF performs systematic literature reviews of published studies, including both randomized control trials and observational studies. The USPSTF did a large review in 2005. Its most recent study, published last year in the Annals of Internal Medicine, focused on research gaps from the last review. In particular, it considered new evidence that it is clinically effective to start antiretroviral therapy treatment earlier, and that taking antiretroviral therapy can dramatically reduce the transmission of HIV.
How does moving testing into routine care affect both the resources required for HIV testing and treatment?
Dr. Martin: My colleague Bruce Schackman and I point out that testing costs are only the tip of the iceberg. We previously estimated that it would cost $2.7 billion over five years to double the frequency of HIV testing at the national level. Four-fifths of these additional costs are due to downstream treatment costs, rather than the cost of HIV testing. Expanded HIV testing is a really good investment, as it is important to identify people earlier in their infection so they can be treated sooner. That can in turn reduce the number of new infections. However, payers need to be prepared to pay for treatment costs, which can be over $20,000 per year.
You mentioned that state laws do not all match the CDC's recommendations. What is happening in New York?
Dr. Martin: Chapter 308 of the Laws of 2010 [in New York State] authorized changes in HIV testing, including simplifying informed consent and pre-test counseling processes, requiring that patients aged 13 to 64 be offered HIV testing in a variety of routine medical settings, and requiring that providers arrange follow-up medical appointments for those testing positive. The recommendations on informed consent and pre-test counseling put New York in line with the CDC's 2006 recommendations. The mandatory offer of HIV testing goes beyond the CDC recommendations, and puts New York ahead of the curve.
What other research are you doing in this area?
Dr. Martin: I recently finished a contract with the New York State Department of Health AIDS Institute with Rod MacDonald where we used simulation modeling to project how different HIV testing law implementation scenarios would change new infections, diagnoses, linkage to care, and living HIV cases in New York. These findings were included in the AIDS Institute's statutory evaluation of the law, which was submitted to the governor's office last fall. This last year I have had the fantastic opportunity to be a member of an Institute of Medicine committee where we reviewed data systems and indicators to monitor HIV care in the U.S. as the Affordable Care Act and the National HIV/AIDS Strategy are implemented. In a second report, we discussed strategies to generate national estimates for HIV care and coverage.
Where can readers go to learn more about these issues?
Dr. Martin: The webpage with the USPSTF draft recommendations on HIV screening will be updated once they are finalized. The CDC website provides detailed information about HIV disease, HIV testing trends, and the CDC's 2006 recommendations. The New York State Department of Health AIDS Institute has a website devoted to New York's HIV testing law. Finally, Bruce Schackman and I have a review paper where we discuss how the Affordable Care Act will affect HIV care.