Voluntary Screening Program Research Articles

Sexually Transmitted Infections and HIV Prevalence among Incarcerated Men Who Have Sex With Men, 2000–2005

: Screening incarcerated populations, particularly men who have sex with men (MSM), for the identification, treatment, and prevention of sexually transmitted infections (STI) and HIV provides an effective way to access a hard-to-reach, high-risk population. : To describe findings from a screening program designed to identify STIs and HIV among incarcerated MSM. : The Los Angeles County Sexually Transmitted Disease Program implemented a voluntary HIV and STI screening program in the segregated MSM unit of the Los Angeles County Men's Jail in March 2000. This analysis reports on data collected through December 2005. : Between March 2000 and December 2005, a total of 7004 inmates participated in the screening program. The overall positivity rate for chlamydia was 3.1% (127 of 4157) and 1.7% (69 of 4106) for gonorrhea. In addition, early syphilis was identified in 1.6% of inmates (95 of 6008) and the overall prevalence of HIV was 13.4% (625 of 4658). The level of repeat testing was relatively high with 15% (1048) of inmates repeatedly incarcerated and screened for STIs over the 5-year period. Although the seroprevalence of HIV was not significantly different between repeaters and nonrepeaters, 33 inmates were HIV seropositive after having tested negative at prior bookings, resulting in an HIV incidence of 1.9%. : Screening incarcerated MSM in Los Angeles revealed a high prevalence of STI and HIV infection. These inmates not only represent a high-risk group, but also a unique opportunity for the identification, treatment, and counseling of this hard-to-reach, high-risk population.

Cost-effectiveness of voluntary HIV screening in Russia.

Russia has one of the world's fastest growing HIV epidemics, and HIV screening has been widespread. Whether such screening is an effective use of resources is unclear. We used epidemiologic and economic data from Russia to develop a Markov model to estimate costs, quality of life and survival associated with a voluntary HIV screening programme compared with no screening in Russia. We measured discounted lifetime health-care costs and quality-adjusted life years (QALYs) gained. We varied our inputs in sensitivity analysis. Early identification of HIV through screening provided a substantial benefit to persons with HIV, increasing life expectancy by 2.1 years and 1.7 QALYs. At a base-case prevalence of 1.2%, once-per-lifetime screening cost $13,396 per QALY gained, exclusive of benefit from reduced transmission. Cost-effectiveness of screening remained favourable until prevalence dropped below 0.04%. When HIV-transmission-related costs and benefits were included, once-per-lifetime screening cost $6910 per QALY gained and screening every two years cost $27,696 per QALY gained. An important determinant of the cost-effectiveness of screening was effectiveness of counselling about risk reduction. Early identification of HIV infection through screening in Russia is effective and cost-effective in all but the lowest prevalence groups.

A targeted population carrier screening program for severe and frequent genetic diseases in Israel

A national carrier screening program targeted at communities in which severe genetic diseases are present with a frequency higher than 1/1000 live births, has been in existence in Israel since 2002. Within the communities at risk, carrier screening is voluntary whereas genetic counseling and testing is provided free of charge. During the first 5 years of the program more than 13 000 tests were performed, and at the end of 2007 it was offered in 35 different localities/communities for a total of 36 diseases. Many of the couples identified to be at risk opted for prenatal diagnosis and in two cases an affected pregnancy was terminated. In some cases the couples declined prenatal diagnosis and two of those families gave birth to an affected child. Based on the experience learnt from this targeted screening program it appears that a knowledge-based, voluntary screening program operated within the community is an effective way to provide genetic services and test referrals. The community program directed toward couples in their reproductive period does not seem to have led to stigmatization at either the individual or the community level.

CKD and Cardiovascular Disease in Screened High-Risk Volunteer and General Populations: The Kidney Early Evaluation Program (KEEP) and National Health and Nutrition Examination Survey (NHANES) 1999-2004

Chronic kidney disease (CKD) is recognized as an independent cardiovascular disease risk state. The relationship between CKD and cardiovascular disease in volunteer and general populations has not been explored. The National Kidney Foundation Kidney Early Evaluation Program (KEEP) is a community-based health-screening program to raise kidney disease awareness and detect CKD for early disease intervention in individuals 18 years or older with diabetes, hypertension, or family history of kidney disease, diabetes, or hypertension. KEEP volunteers completed surveys and underwent blood pressure and laboratory testing. Estimated glomerular filtration rate (eGFR) was computed, and urine albumin-creatinine ratio (ACR) was measured. In KEEP, CKD was defined as eGFR less than 60 mL/min/1.73 m(2) or ACR of 30 mg/g or greater. Cardiovascular disease was defined as self-reported myocardial infarction or stroke. Data were compared with National Health and Nutrition Examination Survey (NHANES) 1999-2004 data for prevalence of cardiovascular disease risk factors and cardiovascular outcomes. Of 69,244 KEEP participants, mean age was 53.4 +/- 15.7 years, 68.3% were women, 33.0% were African American, and 27.6% had diabetes. Of 17,061 NHANES participants, mean age was 45.1 +/- 0.27 years, 52% were women, 11.2% were African American, and 6.7% had diabetes. In KEEP, 26.8% had CKD, and in NHANES, 15.3%. ACR was the dominant positive screening test for younger age groups, and eGFR, for older age groups, for both populations. Prevalences of myocardial infarction or stroke were 16.5% in KEEP and 15.1% in NHANES (P < 0.001) and 7.8% in KEEP and 3.7% in NHANES (P < 0.001) for individuals with and without CKD, respectively. In adjusted analysis of both KEEP and NHANES data, CKD was associated with a significantly increased risk of prevalent myocardial infarction or stroke (odds ratio, 1.34; 95% confidence interval, 1.25 to 1.43; odds ratio, 1.37; 95% confidence interval, 1.10 to 1.70, respectively). In KEEP, short-term mortality was greater in individuals with CKD (1.52 versus 0.33 events/1,000 patient-years). CKD is independently associated with myocardial infarction or stroke in participants in a voluntary screening program and a randomly selected survey population. Heightened concerns regarding risks in volunteers yielded greater cardiovascular disease prevalence in KEEP, which was associated with increased short-term mortality.

Hepatitis C in Psychiatry Inpatients: Testing Rates, Prevalence and Risk Behaviours

Estimates for the prevalence of hepatitis C among people with a serious mental illness are high compared with the general population. High-risk behaviours commonly associated with mental illness may contribute to the estimated increased prevalence. This study aims to assess the contribution of risk behaviours to blood-borne virus infection in psychiatric populations in Australia, and to determine whether a pre- and post-test education and counselling program increases the number of patients willing to be tested for hepatitis C. The proportion of psychiatric inpatients being screened for hepatitis C at the Alfred Hospital over a 6-month period was obtained by retrospective review of the number of admissions and hepatitis C serology tests. The change in screening rate was prospectively recorded following the introduction of an education and voluntary screening program. In the study period, 346 people were approached and 84 (24%) agreed to participate. Pre- and post-test counselling, including a thorough risk assessment, were offered to all participants. Venous blood was tested for hepatitis C. A modified version of the Risk Behaviour Questionnaire was used to measure sexual and drug-related risk behaviour. The proportion of inpatients being tested for hepatitis C increased from 9% in the 6 months prior to the study, to 18% during the study (p <0.01). The rate of hepatitis C in those consenting to testing was 19.4%. Participants reported high rates of risk-taking behaviours, including intravenous drug use and unprotected sex. An education and counselling program can increase rates of screening among psychiatric inpatients. There are high rates of risk-taking behaviour among this group of psychiatric inpatients, which may contribute to the higher prevalence of hepatitis C compared to the general population.

A Nascent HIV Type 1 Epidemic among Injecting Drug Users in Kabul, Afghanistan Is Dominated by Complex AD Recombinant Strain, CRF35_AD

Injecting drug use (IDU), common in global centers of heroin production, confers significant risk for HIV-1 infection. Once introduced into IDU networks, an explosive rise in HIV-1 infection typically occurs, fueled principally by needle sharing. New HIV-1 epidemics in IDUs have occurred in Russia, China, Thailand, Spain, Iran, and in other countries, and some have spread into other risk groups in their respective countries. In Afghanistan, the introduction of HIV-1 into IDU networks has begun, but a recent report of 3% HIV-1 prevalence suggests that the epidemic is still at an early stage. Here we establish, by complete genome sequencing and phylogenetic analysis of four viral strains from Afghan IDUs, that all are the same complex recombinant strain, combining HIV-1 subtypes A and D and herein termed CRF35_AD. Published partial HIV-1 sequences from an HIV-1 epidemic among IDUs in Iran, already at 23.2% HIV-1 prevalence, are either CRF35_AD or a related recombinant. Voluntary HIV-1 screening and harm reduction programs in Afghanistan, applied now, could limit the spread of HIV-1, both in IDUs and in other social networks.

Testing for HIV infection in the United States

The process by which HIV-infected individuals are tested and identified has changed with the evolving HIV epidemic and public health response. In this review, we discuss the rationale for increased HIV testing as well as the current standards in HIV diagnostics and their inherent limitations. Current policy guidelines for routine HIV testing from the U.S. Preventive Services Task Force and the U.S. Centers for Disease Control and Prevention are divergent. However, national momentum toward the implementation of routine HIV testing programs continues based on the efficacy and feasibility of these programs in terms of HIV case identification and on recent reports of their cost-effectiveness. As routine, voluntary HIV screening programs are established, issues surrounding consent, reporting, and stigma still persist, as does the challenge of effectively linking detected HIV cases to care.

Perfil do câncer de próstata no hospital de clínicas de Porto Alegre

To describe prevalence and features of prostate cancer in the sample. A five year long voluntary screening program was carried out in the "Hospital das Clínicas de Porto Alegre" with the participation of 3,056 patients in a cross sectional study. For statistical analysis the chi square test was used, considering a significance level of p < 0.05 Mean age of the sample was of 60.4 years and prevalence of prostate cancer was of 2.61%, increasing with age. Sensitivity and specificity of PSA were respectively 93.8% (CI = 85.4% to 97.7%) and 82.5% (CI = 81.1% to 83.8%), considering 4 ng/ml as the cut-off point for PSA. Rectal examination had a sensitivity of 60% (CI = 48.4% to 70.6%) and a specificity of 83.3% (CI = 81.9% to 84.6%) The number of biopsies performed for the diagnosis of a patient with prostate cancer was 11.9 and varied according to age. As for clinical staging, 51.3% of patients were T1C and 83.75% of the tumors were clinically confined to the organ. Screening programs can be performed in our environment and direct to a frequent diagnosis of patients with prostate cancer confined to the organ.

Economic evaluation of HIV screening in pregnant women attending antenatal clinics in India

Objective With prevalence of HIV rising in pregnant women in India, pediatric HIV/AIDS is emerging as a public health problem. We evaluated the additional costs to the health care system and the additional health outcomes of introducing a voluntary primary care HIV screening program for pregnant women in India. Methods The analysis was conducted from the government perspective. We analyzed two scenarios: a programme of universal screening nation-wide and a programme of screening restricted to high prevalence states. Health benefits were measured by the number of perinatal HIV cases prevented and the reduction in the potential years of life lost (PYLL). Findings Nation-wide screening would cost the government Rs. 254.78 million and would prevent 9880 cases of perinatal HIV resulting in savings of 131,700 life years (average cost per HIV case prevented Rs. 25,787; per year reduction in PYLLs Rs. 1935). Implementing the program in only the high prevalence states would achieve 45% of these reductions in cases and life years lost at only 20% of this cost, at an average of Rs. 12,091 per HIV case prevented or Rs. 907 per year reduction in PYLLs (44 Indian rupees = US$ 1). In sensitivity analysis, the cost of the program was influenced mainly by antenatal coverage, the cost of the HIV test, the lifetime costs of treatment of a HIV infected child and the overhead costs. Conclusions We provide an estimate of the additional costs and health effects of two approaches to introducing HIV screening among pregnant women in India. Decision-makers would have to demonstrate that the resources used for its implementation would result in more health benefits than from the alternative uses of those resources.

Albuminuria in a remote South Australian Aboriginal community: results of a community-based screening program for renal disease

The poverty, poor environmental living conditions and poor health standards experienced by Aboriginal Australians in some communities in rural and remote Australia have been described recently as 'fourth world'. For more than a century Aboriginal people have suffered the effects of dispossession of their land; destruction of their traditional culture and values; and exposure to infectious diseases, alcohol and the Western diet that is high in fat and sugar. Collectively these factors have contributed to the prevalence of chronic disease that afflicts Aboriginal people. In particular, renal disease has emerged during the last decade as a major contemporary health problem for Aboriginal Australians. According to the latest age- and sex-adjusted figures, Aboriginal people now have approximately nine-fold the risk of non-Aboriginal Australians of developing end-stage renal disease. In parts of Australia's Northern Territory, where Aboriginal people represent over 20% of the Territory's population, the rates of end-stage renal disease have been described as 'epidemic', reaching 2700 per million in the Tiwi Islands. In response to a request from the Umoona Tjutagku Health Service in mid 1997, the Renal Unit at Flinders Medical Centre, Adelaide, South Australia, formed a partnership with the health service to conduct a renal-disease screening program for adult members of the Umoona Community at Coober Pedy, a town 850 kilometres north of Adelaide. The partnership was later expanded to include screening for children (conducted by the Renal Unit at the Women's and Children's Hospital, Adelaide, South Australia). The community named the program 'The Umoona Kidney Project'. The Umoona community had recently experienced the dislocation of a number of its older people who suffered from advanced renal disease and were undergoing dialysis in a variety of centres in South Australia and the Northern Territory. As a result, the community had suffered social trauma. Consistent with the community's overall holistic approach to healthcare, the community wanted the renal program to provide a focus for community awareness of and knowledge about chronic disease, as well as to complement existing health programs. The study objectives were to identify the prevalence of risk factors for renal disease, notably albuminuria, in adults from a remote Aboriginal community, and to examine the association of albuminuria with other risk factors; to empower Aboriginal health workers to self-manage a sustainable, community-controlled renal health program; and to assess the reliability and cultural acceptability of point-of-care technology for detecting renal disease. The study was a three-year cross-sectional voluntary adult screening program (The Umoona Kidney Project). The study was performed as a partnership between the Flinders Medical Centre Renal Unit and the Umoona Tjutagku Health Service, and it involved nephrologists, medical scientists, Aboriginal health workers and clinical nurses. Umoona Tjutagku Health Service, 850 km north of Adelaide. 158 adult members of the Umoona community: 58 males (37%; mean age = 43.8 years, range 23-78) and 100 females (63%; mean age = 39.6 years, range 18-72). First morning urine albumin : creatinine ratio measured by the Bayer DCA 2000 point-of-care analyser machine (Bayer Australia, Melbourne, Australia); lying and standing blood pressure; random blood glucose; body mass index; urinalysis. The study found that of screened adults, 29/149 (19%, 95% C.I. 13%-27%) had persistent microalbuminuria and 13/149 (9%, 95% C.I. 4%-14%) had persistent macroalbuminuria; 62/148 participants (42%, 95% C.I. 34%-50%) had overt hypertension; 35/145 participants (24%, 95% C.I. 17%-32%) had diabetes; 3 participants were newly diagnosed as having non-insulin dependent diabetes; 96/148 participants (65%, 95% C.I. 57%-73%) were either overweight or obese. Strong correlation was observed between the progression of albuminuria and age, all blood pressure categories, blood glucose, body mass index and an increasing number of risk factors. The Umoona Kidney Project identified a significant community burden of previously unknown incipient and established renal disease that required addressing via clinical- and community-based interventions. The DCA 2000 was a reliable instrument for detecting albuminuria on-site in the remote clinical location and was well accepted by Aboriginal health workers and community participants.

The Irish paradigm on the natural progression of hepatitis C virus infection: An investigation in a homogeneous patient population infected with HCV 1b (review)

The aetiological agent of chronic hepatitis C is the hepatitis C virus. The hepatitis C virus is spread by parenteral transmission of body fluids, primarily blood or blood products. In 1989, after more than a decade of research, HCV was isolated and characterised. The hepatitis C viral genome is a positive-sense, single-stranded RNA molecule approximately 9.4 kb in length, which encodes a polyprotein of about 3100 amino acids. There are 6 main genotypes of HCV, each further stratified by subtype. In 1994, a cohort of women was identified in Ireland as having been iatrogenically exposed to the hepatitis C virus. The women were all young and exposed as a consequence of the receipt of HCV 1b contaminated anti-D immunoglobulin. The source of the infection was identified as an acutely infected female. As part of a voluntary serological screening programme involving 62,667 people, 704 individuals were identified as seropositive for exposure to the hepatitis C virus; 55.4% were found to be positive for the viral genome 17 years after exposure. Of these women 98% had evidence of inflammation, but surprisingly, a remarkable 49% showed no evidence of fibrosis. Clinicopathology and virological analysis has identified associations between viral load and the histological activity index for inflammation, and, between inflammation and levels of the liver enzyme alanine aminotransferase. Infection at a younger age appears to protect individuals from progression to advanced liver disease. Molecular analyses of host immunogenetic elements shows that particular class II human leukocyte associated antigen alleles are associated with clearance of the hepatitis C virus. Additional class II alleles have been identified that are associated with stable viraemia over an extended period of patient follow-up. Although, investigation of large untreated homogeneous cohorts is likely to become more difficult, as the efficacy of anti-viral therapy improves, further investigation of host and viral factors that influence disease progression will help provide an evidence based approach were realistic expectations regarding patient prognosis can be ascertained.

Serving the Family From Birth to the Medical Home

Newborn screening in the United States is a public health program aimed at the early identification of conditions for which early and timely interventions can lead to the elimination or reduction of associated mortality, morbidity, and disabilities. This screening takes place within the context of a newborn screening system, and involves the following components: screening, short-term follow-up, diagnosis, treatment/management, and evaluation. Inherent to each of these components is an education process. The screening programs like these for the 4 million infants born each year in the United States have been heralded as successful and cost-effective.1–5 The newborn screening program's efficiency and effectiveness depends on the smooth integration of sample collection, laboratory testing, follow-up, diagnosis, timely treatment, and tracking of outcomes.6–11 The foundation and justification of newborn screening systems rest on the principles that testing procedures are readily available; technically feasible; economically sound; and clearly beneficial to affected newborns, their families, and to society.10,12–14 The universal acceptance of newborn screening for specified conditions over the past 3 decades attests to the undeniable benefits that flow from early testing and prompt, appropriate therapy. However, although newborn screening systems have succeeded in preventing morbidity and mortality, controversies, challenges, and opportunities continue. ### The History of Newborn Screening Newborn screening programs began in the early 1960s with the original work of Dr Robert Guthrie, who developed a screening test for phenylketonuria (PKU) and a system for collection and transportation of blood samples on filter paper.15,16 By 1962, Massachusetts launched a voluntary newborn PKU screening program that demonstrated the feasibility of mass genetic screening.17 Initially, newborn screening for PKU was not a health department role or a legislated activity. Health professionals were slow to adopt the practice of screening for PKU, and the responsibility for screening was not defined (eg, should it be the responsibility of …

HIV Infection among Pregnant Women in Bobo-Dioulasso, Burkina Faso: Comparison of Voluntary and Blinded Seroprevalence Estimates

The objective of our study was to estimate the prevalence of HIV infection among pregnant women in Bobo-Dioulasso (Burkina Faso) according to 2 survey methods. Unlinked anonymous HIV screening was performed among women attending 2 antenatal clinics. Voluntary and confidential HIV counselling and testing were offered to women attending 2 other antenatal clinics in the same time period, September-October 1996. Voluntary HIV testing was performed in the context of a clinical trial on mother-to-child transmission of HIV (ANRS 049 clinical trial) with an acceptance rate of HIV testing of 93%. The first survey recruited 200 women and the second, 424. The mean age (24.6 years vs 24.8 years) and the mean number of pregnancies (3.1 vs 3.3) of women were comparable, in the 2 studies (P=0.69 and P=0.26, respectively). Prevalence of HIV infection in the blinded survey was estimated at 10.0% (95% confidence interval (CI): 6.4-15.2), while it was 9.4% (95% CI: 6.9-12.7) in the voluntary HIV screening programme. These 2 estimates were not statistically different (P=0.82). In the voluntary screening study, the prevalence of HIV infection was significantly different between age groups 15-24 years and 25-49 years (13.9% vs 4.5%, P < 0.001). In the age group 25-49 years, the prevalence of HIV infection estimated in the blinded study and in the voluntary screening study were significantly different (10.5% vs 4.5%, P=0.04) suggesting a potential participation bias among pregnant women of older age in the voluntary, confidential HIV screening group. In conclusion, for the purpose of HIV surveillance, the most reliable method for HIV prevalence remains the unlinked, anonymous testing.

Emergency Department–Based HIV Screening and Counseling: Experience With Rapid and Standard Serologic Testing

Study objective: We sought to (1) determine whether some emergency departments could play an important role in the national strategy of early HIV detection through the implementation of a voluntary HIV screening program and (2) describe the experience with standard and rapid HIV testing. Methods: Consenting adults were enrolled during 3 distinct phases between 1993 and 1995 for the assessment of routine testing only, routine versus rapid testing, and rapid testing only. Patients administered the rapid test were given information at the time of the visit. We assessed the cost of the program. Results: Of 3,048 patients approached, 1,448 (48%) consented, 981 to standard and 467 to rapid testing. Of these, 6.4% and 3.2%, respectively, were newly identified as being HIV seropositive. More than twice as many new infections were diagnosed among those discharged from the ED as among those admitted (55 versus 21). Even among those previously tested, 5% proved seropositive. The mean±SD time to obtain results for the rapid assay performed in the hospital’s main laboratory was 107±52 minutes, with 55% leaving the ED before receiving the results. Rapid assays performed in the ED satellite laboratory required 48±37 minutes, and only 20% left before getting the results. Follow-up among HIV-seropositive patients was 64% for the standard protocol and 73% for the rapid protocol ( P >.20). The prearranged HIV clinic intake appointment was kept by 62%. Rapid test sensitivity and specificity were 100% and 98.9%, respectively, with 5 initial false-positives and no false-negatives. Cost per patient enrolled and counseled was $38. Cost per infection detected was $601 for the routine test and $1,124 with the rapid test; these prices are competitive with those incurred at other sites. Conclusion: Emergency department–based HIV testing was well accepted and detected a significant number of new HIV infections earlier than might have otherwise been, particularly among patients sent home. The rapid test is best performed on-site and is very sensitive. Confirmation of initial results is required because of the occurrence of occasional false-positive results. With relatively high HIV detection and return rates, it is evident that some EDs could play a major role in the national strategy of early HIV detection. [Kelen GD, Shahan JB, Quinn TC, and the Project Educate Work Group: Emergency department–based HIV screening and counseling: Experience with rapid and standard serologic testing. Ann Emerg Med February 1999;33:147-155.]

The cost-effectiveness of HIV testing: accounting for differential participation rates.

To understand the impact of differences in participation rates between infected and uninfected individuals on estimates of the cost-effectiveness of HIV screening. Costs per infection detected are modeled as function of both prevalence and serostatus-dependent testing rates. Data from national surveillance surveys, seroprevalence studies, and other sources are employed to suggest the magnitude of results. Differential participation produces a near-doubling in the estimated cost per infection identified. This result is sensitive to assumptions regarding the benefits of screening for seronegatives. Voluntary HIV screening programs may incur prohibitive costs by over-recruiting people at little risk of infection. Failure to account for differential participation can result in over-optimistic cost-effectiveness estimates. However, the relevance of this result--and the significance of both prevalence and participation as cost drivers--is overwhelmed by what is assumed about the benefits conferred to uninfected people by HIV screening.

Effectiveness of community-based screening for depression.

The effectiveness of a voluntary depression screening program was assessed by determining 1) whether participants in the 1994 National Depression Screening Day went for recommended follow-up examinations and 2) the characteristics that differentiated those who did and did not return. Randomly selected participants (N = 1,169) from 99 facilities completed a follow-up telephone survey. Of 805 people for whom follow-up was recommended, 56.5% (N = 455) went for an appointment. The severity of depressive symptoms in these subjects ranged from severe (33.4%, N = 152) and marked (41.3%, N = 188) to minimal (17.1%, N = 78) and normal (8.1%, N = 37). Subjects with marked or severe depression were more likely to respond to the screening recommendation than were those with minimal depressive symptoms. However, at each level of symptom severity, subjects who had received previous treatment were more likely to adhere to the screening recommendation than were those with no previous treatment. Of those who returned for a recommended follow-up, 72.1% were diagnosed with depression. Of those who did not return, 29.5% cited lack of insurance, under insurance, or inadequate finances, and 38.0% felt they could "handle" depression on their own. Voluntary screening for depression is an effective way to bring certain untreated depressed individuals to treatment. Inadequate insurance and the belief that individuals can manage depression on their own continue to be barriers to seeking treatment among some depressed individuals who attend a depression screening program.

Newborn screening for 21-hydroxylase deficiency: Results of CYP21 molecular genetic analysis

Blood samples for plasma steroid hormone determinations and molecular genotype analysis of the 21-hydroxylase gene (CYP21) were obtained from 15 infants identified through a voluntary newborn screening program. Mutations were identified on both CYP21 alleles in 12 (80%) of 15 infants; all had confirmatory plasma 17-hydroxyprogesterone concentrations>3500 ng/dl. No patient was found to carry mutations associated with late-onset 21-hydroxylase deficiency. Newborn screening hastened diagnosis in eight infants. (J Pediatr 1997;131: 328-31)

Primary prevention in a high-risk group: smoking habits in adolescents with homozygous alpha-1-antitrypsin deficiency (ATD).

The serious form of alpha-1-antitrypsin deficiency (ATD) Pi ZZ strongly predisposes the individual for pulmonary emphysema and premature death in adulthood, especially if exposed to tobacco smoking. General screening of all new-born children was conducted in Sweden during 1972-1974, the major purpose being to reduce exposure of the child to parental smoking while growing up and to prevent the child from starting to smoke. Sixty-one children with ATD neonatally identified through mass-screening, and their families, have been compared with a demographically matched control group regarding smoking habits, as studied through interviews and questionnaires on two occasions. When the children were 5-7 years old, the smoking rates among parents of the ATD children and especially among the ATD fathers exceeded smoking rates for controls. Thirteen years later no differences in parental smoking were found between the groups. At 18-20 years of age the ATD children reported smoking significantly less than the control children (p < 0.05). From the perspective of prevention, the goal of the neonatal screening to reduce the smoking rates among the parents of the ATD children was not attained, while it was achieved among the ATD children. The results indicate that a screening program with early detection of ATD effectively prevents adolescent children from starting to smoke. From ethical, medical and psychological points of view, a voluntary screening program for ATD in pre-adolescence is recommended.

Economic Impact of Treatment of HIV-Positive Pregnant Women and Their Newborns With Zidovudine

To estimate the economic impact of (1) treating pregnant women who are human immunodeficiency virus (HIV)-positive with zidovudine and (2) voluntary screening programs for pregnant women for HIV infection and offering treatment with zidovudine to those found to be HIV-positive. Number of cases of pediatric HIV infection and costs of screening, zidovudine treatment, and pediatric HIV infection treatment. Health care costs associated with treatment of HIV-positive pregnant women and their newborns are estimated as the costs of zidovudine and its administration and the reduction in costs of treating pediatric HIV infection. The lifetime costs of pediatric HIV infection are derived from the published literature. Estimates of the reduction in maternal-to-fetal transmission rates are taken from the AIDS [acquired immunodeficiency syndrome] Clinical Trials Group (ACTG) Protocol 076. Costs of a voluntary screening program include costs of screening tests and counseling. Sensitivity and threshold analyses are performed to determine the impact of changes in input parameter values including zidovudine treatment costs, efficacy of treatment, costs of pediatric HIV infection, prevalence of HIV infection in pregnant women, screening test sensitivity and specificity, and pregnancy termination rates on the results. Assuming transmission rates are reduced from 25.5% to 8.3% as found in the ACTG 076 trial, treatment costs of $104,502 for 100 HIV-positive pregnant women and their newborns are offset by the reduction of $1,701,333 associated with fewer cases of pediatric HIV infection for a net savings of $1,596,831. The sensitivity and threshold analyses show that overall cost savings from treatment of HIV-positive pregnant women and their newborns are achieved for a wide range of possible maternal treatment costs, efficacy rates, and lifetime pediatric HIV treatment costs. In the base-case analysis for the voluntary screening program, overall cost savings are seen when HIV prevalence rate among pregnant women is greater than 4.6 per 1000. However, this threshold prevalence rate is sensitive to changes In parameter value-especially pediatric HIV treatment costs, counselling costs, efficacy of treatment, and years of additional HIV treatment for the pregnant women. Offering zidovudine treatment to pregnant women known to be HIV-positive will decrease the number of cases of pediatric HIV infection and reduce health care costs. Voluntary screening programs for pregnant women will further decrease the number of cases of pediatric HIV infection. The effect of a screening program on health care costs varies according to HIV prevalence and the costs associated with the screening program.

Feasibility of an Emergency Department–Based, Risk-Targeted Voluntary HIV Screening Program

Study objective: To assess the feasibility and effectiveness of an emergency department–based, risk-targeted voluntary HIV screening program. Methods: We prospectively enrolled consenting adult IV drug users (IDUs) not known to have HIV infection in the ED of a large inner-city hospital with a high rate of HIV infection among patients during a 10-week trial. Study patients were given confidential HIV pretest and risk-reduction counseling, with 10- to 14-day on-site ED follow-up. Follow-up included posttest counseling, reinforcement of risk-reduction practices, and a $10 incentive to cover transportation costs. HIV seropositive patients were referred to the hospital HIV clinic for further evaluation and treatment. Results: Of 200 eligible IDUs, 168 (84%) consented to HIV testing. Of the 104 (62%) who returned for follow-up, 17 (16%) tested positive for HIV. Of these patients, 6 (35%) kept their initial hospital HIV clinic referral appointment, a rate consistent with the experience of the hospital HIV clinic. Of nine patients in whom CD4+ counts were performed at time of the visit, three (33%) had counts less than 200. At 3-month follow-up, 4 of 20 active IDUs (20%) had reportedly ceased drug use because of the program. The complete program cost was an estimated $16,659, $99 per enrolled patient and $521 per HIV-positive patient. Conclusion: An ED-based, risk-targeted HIV screening program is feasible and over time could detect a significant number of asymptomatic HIV-infected individuals, including those who should receive antiretroviral therapy and prophylaxis for Pneumocystis carinii pneumonia therapy (CD4+ count less than 200). An additional benefit of ED-based HIV screening in high-prevalence EDs is the opportunity to conduct successful risk-reduction counseling in some high-risk individuals. [Kelen GD, Hexter DA, Hansen KN, Humes R, Vigilance PND, Baskerville M, Quinn TC: Feasibility of an emergency department–based, risk-targeted voluntary HIV screening program. Ann Emerg Med June 1996;27:687-692.]