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

The figure identifies the evolution of the boundary between current practice (that is, no specific screening program) and one-time HIV screening as a function of 3 factors: 1) the prevalence of HIV in the target population (vertical axis); 2) the impact of care on secondary transmission, ΔR₀ (horizontal axis); and 3) the value that society is prepared to pay to purchase an additional quality-adjusted life-year (QALY) of health for its citizens (as measured by the threshold cost-effectiveness ratio). Each prevalence value is associated with a specific incidence assumption (see Methods section for details). The figure reports results for threshold cost-effectiveness ratios ranging from $25 000 to $100 000 per QALY. The dotted lines represent the 3 transmission impact scenarios described in Table 2: “favorable impact,” “no effect of screening and treatment on transmission,” and “adverse impact.” The curves represent the borders of regions over which a given HIV screening strategy is preferred. For example, assuming that society is willing to pay up to $50 000/QALY and an adverse transmission impact, one-time screening is recommended for prevalences above 0.40% (solid circle); if society is willing to pay even more (up to $75 000/QALY), one-time screening is recommended for prevalences above 0.15% (solid square). Assuming no effect of screening and treatment on transmission and a societal willingness to pay $75 000 per additional QALY, one-time screening is recommended for prevalences above 0.10% (solid triangle). At a societal willingness to pay of $100 000/QALY, one-time screening is preferred under almost all plausible scenarios.