A Los Angeles County counseling and testing program for the AIDS virus requires more money per test and turns up a lower percentage of cases of HIV infection than other such programs in the country funded by the federal Centers for Disease Control.
Figures obtained by The Times from the CDC, which pays for most of the county's HIV counseling and testing program, show the county had the worst record of identifying HIV cases among the seven major urban centers receiving special CDC funding grants during 1992, the last full year for which results are available.
For example, New York City, which established the highest rate for finding cases of HIV infection, conducted 46,564 HIV tests during 1992, compared to 25,779 for Los Angeles County. New York identified 2,971 HIV positives, in contrast to 345 for the county--a "hit" rate of 6.4% versus 1.3%. New York achieved its results on a grant of $4.9 million; Los Angeles County received $4.5 million, according to the CDC.
Even Houston, which received about one-third as much money as Los Angeles County did in the same year, performed 25% more tests and identified three times as many cases of infection, according to the CDC figures.
Locally, where non-county health agencies receive a flat $35 from the state to do HIV tests, there are also sharp differences.
Full-year statistics are not available for 1993, but a partial-year analysis prepared for the county's HIV Health Services and Planning Council showed that the city of Long Beach, which has its own public health department, was discovering infections at a rate significantly higher than the county's--2.07% compared to 1.3%--at a much lower cost: $414,000 over a nine-month period for Long Beach compared to $2.2 million over an eight-month period for the county. Even though Long Beach spent substantially less and serves a much smaller geographic area than the county program, it conducted more tests--8,646 compared to 8,619.
The nonprofit Los Angeles Gay & Lesbian Community Services Center conducts about 1,000 tests a month and reports HIV-positive results about 9% of the time.
Los Angeles County health officials complain that such comparisons are simplistic and do not take into consideration the population the county deals with or the far-flung regions it must serve in the 4,000-square-mile region. They say the costs of their testing and counseling program are pushed up by the need to serve a wide-ranging clientele who are at high risk for infection but who often balk at taking the test when approached at county health centers.
But critics say that broad target population is part of the problem. The county, they contend, should concentrate primarily on those at high risk for HIV infection.
The county "isn't getting results," complained Michael Weinstein, president of the AIDS Healthcare Foundation and the spearhead of criticism of the county's testing program for the human immunodeficiency virus. "That's a tragedy because half the people in this county who are HIV-infected don't know it. To break the chain of infection, you need to find the infected person, get them into treatment, and educate them about safer sexual practices."
Recently, Weinstein and other members of the fiscal committee of the HIV planning council voted to recommend that the county be asked to take $1 million of its testing money and use it to give anonymous tests, which are considered less expensive and more likely to turn up positive results than the confidential tests the county currently gives.
Under confidential testing, the identity of the person receiving the test is known and the test results become a permanent part of his or her health record. County health authorities vow that they keep the results a strictly private matter between them and the patient.
Anonymous tests are considered far more attractive to people who believe they may be infected because they do not carry a risk of harmful repercussions, such as the loss of a job or health insurance. It is generally acknowledged that anonymous tests consistently turn up higher rates of positives than confidential tests.
Another recommendation by the planning council committee was that the county spend $35 per test, the same rate that other agencies receive from the state Department of Health Services for giving the HIV test, along with pre- and post-test counseling. The study undertaken for the HIV planning council disclosed that during the first eight months of 1993, the cost per HIV test at county health centers ranged from $77 to $300, depending on how many tests were performed by each clinic and how many hours were being spent by the staff doing counseling.
"If they can't do it for $35, then they should give the money to someone who can," said Steve Toth, an administrator with a private AIDS program in Long Beach and a member of the fiscal committee who voted for the change with Weinstein.
Given the fact that Los Angeles County has the second-highest number of HIV and AIDS cases in the country, trailing only New York City, and the relative success of other programs, Toth said the county's test results "suggest to me they are testing the wrong population."
Pressed by his critics, John Schunhoff, director of AIDS Programs for the county, recently released a lengthy defense of the HIV testing program, stressing that it targeted people who come to public clinics for treatment of tuberculosis and sexually transmitted diseases or prenatal counseling.
Schunhoff said many hours are devoted to AIDS education and counseling that never turn up in test results, but that it was important to continue trying to reach groups of people who ordinarily would not get an HIV test.
He argued that the county spends more than other programs on HIV testing because county clinics already are understaffed and the large CDC grant was necessary "to staff all clinics and offer HIV testing." Without the money, Schunhoff warned, the clinics might be forced to stop offering HIV counseling and testing.
Dr. Gary Richwald, chief of the county's program on sexually transmitted diseases, said that a "hit" rate of 1% sounded low, but actually was respectable considering that the county numbers were generated from a group of people who were not likely to walk in off the street for an HIV test, as was the case in community clinics. Many of the people who tested positive for HIV initially turned up at the county clinic because they were suffering from syphilis or some other sexually transmitted disease, he said.
"At our sexually transmitted disease clinics, we are treating the poorest of the poor. Our clinics are the clinics of last resort. When they come in we have a lot to talk about," he said.
Richwald said it is crucial for county health authorities to be able to continue conducting confidential tests because knowing a person's HIV status is critical in deciding a course of treatment for a person suffering from other diseases, such as syphilis.
Dr. Ron Valdiserri, the deputy director of the CDC's division of sexually transmitted diseases and HIV prevention, said the federal agency had no performance measurement on its grants for HIV testing and counseling. No guidelines exist on how many tests were to be administered, at what price, or how many HIV-infected people the health agencies were expected to find with the millions in federal dollars they receive, Valdiserri said.
He said that all seven cities were given the same basic contract, or blueprint, on how they were to run their programs.
Critics contend that one reason for the county's low rate for detecting infected people is that it is not testing in the right places. Valdiserri said that health departments receiving the grants were directed to provide the tests "at sites where (health workers) are likely to encounter individuals at risk for HIV infection."
But he said he had no problem with the county's approach of testing at clinics that did prenatal counseling or saw patients for sexually transmitted diseases.
"If the (county's) counseling served a risk reduction or health education purpose," he said, "then the money was not wasted."
In 1992, the U.S. Centers for Disease Control provided health agencies in seven target metropolitan areas with special cash grants to test for the AIDS virus. One source estimates that there are 25,000 people in Los Angeles County infected with the human acquired immunodeficiency virus who don't know it. Here are the results, showing the number of tests given and how many of the subjects tested positive for the virus.
LOCATION TESTS POSITIVES CDC GRANT *Chicago 20,863 542 $1.6 million *District of Columbia 21,308 901 $1.8 million *Houston 34,420 995 $1.2 million *L.A. County 25,779 345 $4.4 million *New York City 46,564 2,971 $4.9 million *Philadelphia 31,209 1,117 $1.7 million *San Francisco 28,304 1,639 $2.4 million
Source: U.S. Centers for Disease Control