Free HIV tests cheaper than charging when goal is preventing AIDS



Collaborative medicine: Nathan Thielman, M.D., center, analyzes patient histories at a clinic in Moshi, Tanzania, with a visiting doctor from West Africa. Thielman is an associate professor of infectious diseases and medicine at Duke University Medical Center.
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Offering free HIV tests instead of charging a small fee is more cost-effective at preventing HIV infections and draws in three times as many people for testing, according to a Duke University Medical Center study conducted in Tanzania.

The Duke researchers provided free HIV tests and counseling during a two-week pilot program in 2003. The number of people seeking tests increased from 4.1 per day before the free testing interval to 15.0 per day during the pilot program. However, the number decreased to 7.1 people per day after the small fee 1,000 Tanzania shillings or 95 U.S. cents was reinstated. When only four people per day were tested at the clinic, it cost $170 to avert an HIV infection, the study showed. But when the testing rate jumped to 15 people per day, the price of preventing an HIV infection dropped to $92 each, even without the revenue from fees. The cost includes everything required to run a testing program staff salaries, laboratory supplies and test kits, utilities and office supplies.

The study results were so striking that the Duke researchers sought additional funding to continue free testing in partnership with a community-based AIDS service organization in Moshi, Tanzania, said lead author Nathan Thielman, M.D. They have since tested more than 4,000 people, he said.

The results appear in the January 2006 issue of the American Journal of Public Health. Funding was provided by Roche Laboratories; the National Institutes of Allergy and Infectious Diseases, part of the National Institutes of Health; and awards from the U.S. Department of State Fulbright Program to Nathan Thielman and Helen Chu.

"I think there is an important policy message here," said Thielman, an associate professor of infectious diseases and medicine at Duke University Medical Center. "Providing free HIV tests increases the number of clients presenting for evaluation and makes HIV prevention more cost-effective. We changed our practice because of these results," Thielman said.

The Duke team partnered with the nongovernmental organization KIWAKKUKI, an acronym for the Swahili name of "Woman Against AIDS in Kilimanjaro." Founded in 1990, KIWAKKUKI provides home-based case, counseling and information about HIV and orphan care and assistance.

"They are a remarkable group of women doing the hard work of taking care of AIDS patients for the long-term. They asked us to provide an HIV testing program as a means of promoting behavioral changes, and that's really the genesis of this project," Thielman said.

The KIWAKKUKI program started offering HIV tests and counseling in March 2003 for just about a dollar the median income in Tanzania is around $564. The HIV infection rate in Tanzania is about 8.8 percent, though about 16.7 percent of those tested at KIWAKKUKI are HIV positive, Thielman said.

The free testing period was promoted with a modest advertising campaign. Once the free trial began, KIWAKKUKI's AIDS Information Center was deluged with clients. "Our colleagues at KIWAKKUKI called it the 'crash' period because it was kind of crazy," Thielman said, with nearly four times as many people coming in on some days for the free HIV tests from 4 people per day to 15 or more. Even after the fee was reinstated, the testing numbers stayed higher than before, about 7 people per day. When the Duke team received funding to continue the free testing, the census rebounded to about 15 to 18 people testing per day.

"It's amazing to me that the numbers are so high. The demand is there people want to know if they are infected," said senior study author John Crump, M.D., a Duke assistant professor of medicine who works full-time at the Kilimanjaro Christian Medical Centre in Tanzania. "One reason is because there is much greater access now to antiretroviral therapy."

Thielman acknowledges that the cost of free testing is a significant factor for organizations with limited resources. "Cost is probably the biggest barrier, but if the goal is to prevent HIV infection, free HIV testing and counseling provides outstanding bang for your buck," he said.

"Right now there is a lot of emphasis on treatment, which is appropriate, but prevention is also important, and HIV testing clearly helps to avert HIV infections," Thielman said. "For every $92 invested in free HIV testing and counseling at an organization such as KIWAKKUKI, an HIV infection can be averted," he said.

Research has shown that HIV testing and counseling reduces high-risk sexual behavior and prevents HIV transmission, Thielman said. Testing also gives people access to services such as antiretroviral therapy, treatment for sexually-transmitted diseases and prevention of mother-to-child HIV transmission.

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Co-authors include Helen Y. Chu, M.D., of Duke; Jan Ostermann, Ph.D., of the Terry Sanford Institute of Public Policy at Duke; Dafrosa K Itemba, KIWAKKUKI; Anna Mgonja, KIWAKKUKI; Sabina Mtweve, M.D., KIWAKKUKI and Kilimanjaro Christian Medical College of Tumaini University, Moshi, Tanzania; John A. Bartlett, M.D., of Duke; and John F. Shao, M.D., Ph.D., of Tumaini University.


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