Free HIV Tests Cheaper than Charging When Goal is Preventing AIDS
DURHAM, N.C. -- 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
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
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
"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
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
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.