Correspondence

Cost of HIV Testing in the U.S. Army

N Engl J Med 1995; 332:963April 6, 1995

Article

To the Editor:

We summarize the costs per test incurred by the U.S. Army since the establishment of programs to test for the human immunodeficiency virus (HIV) in 1985. These costs are now less than $2.50 per serum specimen, as compared with typical commercial charges elsewhere in the United States of $15 for screening and $50 for confirmatory testing.

HIV testing in the Army is done under contract with accredited commercial laboratories. Quality assurance is carried out by the Walter Reed Army Institute of Research. Screening uses enzyme-linked immunosorbent assays (ELISAs) of HIV type 1 whole viral lysate; repeatedly reactive serum samples are tested by both the Western blot assay and a recombinant enzyme immunoassay.1 The percentage of samples requiring the more expensive Western blot assay has varied over time and according to the ELISA manufacturer. It has always been less than 0.5 percent, and it was 0.2 percent in 1993.

For testing active-duty soldiers and applicants to the military, there is an infrastructure for blood collection, processing, and shipment. The cost per specimen of testing these groups was $4.41 and in 1985 and 19862 and $2.43 in 1994. These costs include the transport of specimens, ELISAs, confirmatory testing (when indicated), and the reporting of results. For testing in the U.S. Army Reserve, in which infrastructure is lacking, costs per specimen are three to four times higher ($10.06 in 1994).

These low testing costs partly result from economies of scale. A total of about 1.1 million specimens are tested each year. Particular contracts cover 60,000 to 600,000 specimens. The military has certain logistic advantages over other segments of society, such as the ability to collect blood from reserve units as a group. For soldiers on active duty, HIV testing is incorporated into routine physical examinations. The incidence of HIV among U.S. soldiers is about 0.3 per 1000 person-years.3,4 Because of the resulting low prevalence of infection and the high specificity of screening tests, more than 99.5 percent of serum specimens are nonreactive for HIV antibodies and require no confirmatory testing. In contrast, testing groups of people with high HIV prevalence involves the additional costs of more frequent confirmatory testing and post-test counseling.

The experience of the U.S. Army demonstrates that large-scale HIV testing can be performed at a low cost per specimen. We believe that such economic efficiency can also be achieved in the civilian sector.

Arthur E. Brown, M.D., M.P.H.
Donald S. Burke, M.D.
Walter Reed Army Institute of Research, Rockville, MD 20850

4 References

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   Damato JJ, O'Bryen BN, Fuller SA, Roberts CR, Redfield RR, Burke DS. Resolution of indeterminate HIV-1 test data using the Department of Defense HIV-1 Testing Program. Lab Med 1991;22:107-113
   

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   Burke DS, Brundage JF, Herbold JR, et al. Human immunodeficiency virus infections among civilian applicants for United States military service, October 1985 to March 1986: demographic factors associated with seropositivity. N Engl J Med 1987;317:131-136
   Full Text | Web of Science | Medline

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   McNeil JG, Brundage JF, Gardner LI, et al. Trends of HIV seroconversion among young adults in the US Army, 1985 to 1989. JAMA 1991;265:1709-1714
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   Cowan DN, Brundage JF, Pomerantz RS. The incidence of HIV infection among men in the United States Army Reserve Components, 1985-1991. AIDS 1994;8:505-511
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Raffaele D'Amelio, Emmanuelle Tuerlings, Olga Perito, Roberto Biselli, Sergio Natalicchio, Stuart Kingma. (2001) A Global Review of Legislation on HIV/AIDS: The Issue of HIV Testing. JAIDS Journal of Acquired Immune Deficiency Syndromes 28:2, 173-179
   CrossRef