Universal HIV testing: is it enough?

Early diagnosis of HIV infection and timely access to medical care can improve treatment outcomes [1] and potentially decrease the risk of transmission [2]. In this issue, Keruly and Moore [3] report a decrease in the presenting CD4 + T cell count from 371 cells/mm 3 in 1990–1994 to 276 cells/mm 3 in 2003–2006 among patients newly presenting for HIV care in a large academic center in the United States. Despite significant advances in antiretro-viral therapy and improved services for persons living with HIV infection, our health care system appears to be less capable of detecting the disease early in its course than it was nearly 2 decades ago. The authors conclude that national implementation of the 2006 Centers for Disease Control and Prevention recommendations for routine HIV testing in health care settings [4] will improve early detection and entry to care. But will universal HIV testing be enough? Although these data support the argument for mainstream HIV testing, they also highlight the issue of universal health care coverage. Keruly and Moore [3] report that, after stratification by demographic characteristics and HIV risk factors, median CD4 + T cell counts at presentation significantly decreased over time for women, men, black patients, and patients who reported intravenous drug use (IDU) and heterosexual exposures as HIV risk factors. One notable exception was for men who have sex with men (MSM). Presenting CD4 + T cells counts among MSM actually improved with time, from 280 cells/mm 3 in 1990–1994 to 332 cells/mm 3 in 2003– 2006. Although proportions of patients of each sex and race remained relatively unchanged over time, the proportion of MSM and patients reporting IDU decreased , and there was a nearly 3-fold increase in persons listing heterosexual sex as a risk factor during 2003–2006. Two questions arise. First, are these changes in patient demographic characteristics driving the decrease in the presenting CD4 + T cell counts? The answer is probably not. Although MSM were the only subjects to have improved CD4 + T cell counts over time, these patients initially had the most advanced HIV disease at presentation, with only a modest gain of 52 cells/mm 3 by 2003–2006. Conversely, all other groups had much higher presenting CD4 + T cell counts in 1990–1994, with large decreases over time, ranging from 76 to 174 cells/mm 3. The second question centers on how HIV testing rates among patients receiving care …