Expanded HIV Screening in the United States: Effect on Clinical Outcomes, HIV Transmission, and Costs

5 December 2006 | Volume 145 Issue 11 | Pages 797-806

Background: An extensive literature supports expanded HIV screening in the United States. However, the question of whom to test and how frequently remains controversial.

Objective: To inform the design of HIV screening programs by identifying combinations of screening frequency and HIV prevalence and incidence at which screening is cost-effective.

Design: Cost-effectiveness analysis linking simulation models of HIV screening to published reports of HIV transmission risk, with and without antiretroviral therapy.

Data Sources: Published randomized trials, observational cohorts, national cost and service utilization surveys, the Red Book, and previous modeling results.

Target Population: U.S. communities with low to moderate HIV prevalence (0.05% to 1.0%) and annual incidence (0.0084% to 0.12%).

Time Horizon: Lifetime.

Perspective: Societal.

Interventions: One-time and increasingly frequent voluntary HIV screening of all adults using a same-day rapid test.

Outcome Measures: HIV infections detected, secondary transmissions averted, quality-adjusted survival, lifetime medical costs, and societal cost-effectiveness, reported in discounted 2004 dollars per quality-adjusted life-year (QALY) gained.

Results of Base-Case Analysis: Under moderately favorable assumptions regarding the effect of HIV patient care on secondary transmission, routine HIV screening in a population with HIV prevalence of 1.0% and annual incidence of 0.12% had incremental cost-effectiveness ratios of $30 800/QALY (one-time screening), $32 300/QALY (screening every 5 years), and $55 500/QALY (screening every 3 years). In settings with HIV prevalence of 0.10% and annual incidence of 0.014%, one-time screening produced cost-effectiveness ratios of $60 700/QALY.

Results of Sensitivity Analysis: The cost-effectiveness of screening policies varied within a narrow range as assumptions about the effect of screening on secondary transmission varied from favorable to unfavorable. Assuming moderately favorable effects of antiretroviral therapy on transmission, cost-effectiveness ratios remained below $50 000/QALY in settings with HIV prevalence as low as 0.20% for routine HIV screening on a one-time basis and at prevalences as low as 0.45% and annual incidences as low as 0.0075% for screening every 5 years.

Limitations: This analysis does not address the difficulty of determining the prevalence and incidence of undetected HIV infection in a given patient population.

Conclusions: Routine, rapid HIV testing is recommended for all adults except in settings where there is evidence that the prevalence of undiagnosed HIV infection is below 0.2%.

Editors' Notes Context Two unsolved problems in HIV screening policy are the maximum cost-effective screening frequency and the minimum HIV prevalence for cost-effective screening. Contribution The authors used a decision model to estimate the cost-effectiveness of same-day rapid test HIV screening, considering outcomes experienced by the infected person and his or her sexual contacts. One-time screening was cost-effective when the prevalence of HIV was as low as 0.20%. Repeated screening every 5 years was cost-effective with an annual incidence of 0.0075% and an HIV prevalence of 0.45%. Cautions The authors did not count HIV transmission from infected contacts. Implications Screening for HIV is cost-effective when HIV prevalence is similar to that of average-risk populations. —The Editors

 

Author and Article Information

From the Yale School of Medicine, New Haven, Connecticut; Massachusetts General Hospital, Harvard Medical School, Brigham and Women's Hospital, and Harvard School of Public Health, Boston, Massachusetts; and Weill Medical College of Cornell University, New York, New York.

Acknowledgments: The authors thank Douglas K. Owens, MD, and several anonymous reviewers for their comments on various drafts of the manuscript. They also thank their colleagues on the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) project team for their valuable guidance: April Kimmel, MSc; Elena Losina, PhD; Alethea McCormick, ScD; Paul Sax, MD; Heather E. Hsu; and Hong Zhang, SM.

Grant Support: By the National Institute of Mental Health (R01MH65869), the National Institute of Allergy and Infectious Diseases (K23AI01794, K24AI062476, R01AI42006, P30AI42851), the National Institute on Drug Abuse (R01DA015612, K01DA0717179), the Doris Duke Charitable Foundation (Clinical Scientist Development Award), and the Centers for Disease Control and Prevention (S1396-20/21).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: A. David Paltiel, PhD, Department of Epidemiology and Public Health, Yale School of Medicine, 60 College Street, New Haven, CT 06520-8034; e-mail, david.paltiel{at}yale.edu.

Current Author Addresses: Dr. Paltiel: Department of Epidemiology and Public Health, Yale School of Medicine, 60 College Street, New Haven, CT 06520-8034.

Drs. Walensky and Freedberg and Ms. Mercincavage: Division of General Medicine, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114.

Dr. Schackman: Department of Public Health, Weill Medical College of Cornell University, 411 East 69th Street, New York, NY 10021.

Drs. Seage and Weinstein: Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.

Author Contributions: Conception and design: A.D. Paltiel, R.P. Walensky, G.R. Seage III, M.C. Weinstein.

Analysis and interpretation of the data: A.D. Paltiel, R.P. Walensky, B.R. Schackman, G.R. Seage III, L.M. Mercincavage, M.C. Weinstein, K.A. Freedberg.

Drafting of the article: A.D. Paltiel, G.R. Seage III, M.C. Weinstein, K.A. Freedberg, R.P. Walensky.

Critical revision of the article for important intellectual content: A.D. Paltiel, R.P. Walensky, B.R. Schackman, G.R. Seage III, L.M. Mercincavage, M.C. Weinstein, K.A. Freedberg.

Final approval of the article: A.D. Paltiel, R.P. Walensky, B.R. Schackman, G.R. Seage III, L.M. Mercincavage, M.C. Weinstein, K.A. Freedberg.

Statistical expertise: G.R. Seage III, M.C. Weinstein.

Obtaining of funding: A.D. Paltiel, K.A. Freedberg.

Administrative, technical, or logistic support: L.M. Mercincavage.

Collection and assembly of data: L.M. Mercincavage.

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