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Impact of the ‘Opt-out’ vs. ‘Opt-in’ Strategy on the Uptake of HIV Counseling and Testing of TB Patients, South Africa

Health care workers trained in the current model of voluntary counseling and testings typically ask a TB patient if he or she wants HIV counseling and testing. The burden of decision-making is placed on the individual patient; to receive HIV counseling the patient must say "yes" to opt-in. Patients newly diagnosed with TB feel sick and are frequently aware of the relationship between TB and HIV. These patients may feel particularly reluctant to say "yes" to opt-in, despite the potentially life-saving benefit of such an opportunity.   

Including HIV counseling as part of the "package" of a routine medical evaluation administered to all adult TB patients would routinize counseling because TB patients would no longer specifically be asked whether they wanted HIV counseling. Patients could refuse counseling, just as a patient can refuse any aspect of medical evaluations, but by providing HIV counseling universally to all TB patients, we believe that fewer patients will refuse and will opt-out. 

This study compared the effect of the opt-out strategy on the uptake of HIV counseling and testing to the standard opt-in approach in newly registered tuberculosis patients. The study randomized 20 TB clinics in the Nelson Mandela Metropolitan Municipality of the Eastern Cape to opt-out or opt-in strategies. 

Data were collected on 754 eligible adult TB cases (? 18 years) covering a 10-week period. A mean of 23% versus 8.7% of the TB cases in the intervention versus control clinics received HIV counseling (t-test, p = 0.03), and 22.4% versus 7.7% received HIV testing (t-test p = 0.03). There were no significant differences in the proportion of patients with a positive HIV test result (36.9% vs. 42.6%), cotrimoxazole prophylaxis (29.6 % vs. 33.3%), and referral for HIV care (36.9% vs. 16.7%) between study arms.  

Use of an opt-out strategy resulted in a significant improvement in the proportion of TB cases counseled and tested for HIV.  Multiple health system factors, in addition to TB nurses’ ambivalence about how and when to properly carry out HIV counseling and testing appear to have contributed to the small magnitude of the effect.

Principal Investigator:  Richard E. Chaisson (JHSPH)


  • Diana Spies Pope (JHSPH)
  • Ashraf Chaudhary (JHSPH)
  • Harry Hausler (University of Western Cape)
  • Andrea DeLuca (JHU Center for Tuberculosis Research)
  • Paula Kali (Medical Consultant)
  • Salla Munro, (University of Cape Town)
  • Carol Sheard (Eastern Cape Province Health Department)
  • Ebrahim Hoosain (Nelson Mandela Metropolitan Municipality)