Objective. To develop a model to assist clinical setting decision makers in determining how much they can spend on human immunodeficiency virus (HIV) screening and still be cost-effective. Design. The authors developed a simple mathematical model relating the program cost per new HIV diagnosis to the cost per HIV infection averted and the cost per quality-adjusted life year (QALY) saved by screening. They estimated outcomes based on behavioral changes associated with awareness of HIV infection and applied the model to US sexually transmitted disease clinics. Methods. The authors based the cost per new HIV diagnosis (2009 US dollars) on the costs of testing and the proportion of persons who tested positive. Infections averted were calculated from the reduction in annual transmission rates between persons aware and unaware of their infections. The authors defined program costs from the sexually transmitted disease clinic perspective and treatment costs and QALYs saved from the societal perspective. They undertook numerous sensitivity analyses to determine the robustness of the base case results. Results. In the base case, the cost per new HIV diagnosis was $2528, the cost per infection averted was $40,516, and the cost per QALY saved was less than zero, or cost-saving. Given the model inputs, the cost per new diagnosis could increase to $22,909 to reach the cost-saving threshold and to $63,053 for the cost-effectiveness threshold. All sensitivity analyses showed that the cost-effectiveness results were consistent for extensive variation in the values of model inputs. Conclusions. HIV screening in a clinical setting is cost-effective for a wide range of testing costs, variations in positivity rates, reductions in HIV transmissions, and variation in the receipt of test results.
Centers for Disease Control and Prevention. Advancing HIV prevention: new strategies for a changing epidemic—United States. MMWR Morb Mortal Wkly Rep. 2003;52(15):329–32.
2.
White House Office of National AIDS Policy. National HIV/AIDS Strategy for the United States. Washington, DC: White House; 2010.
3.
Centers for Disease Control and Prevention. Vital signs: HIV testing and diagnosis among adults—United States, 2001–2009. MMWR Morb Mortal Wkly Rep. 2010;59(47):1550–5.
4.
MarksGCrepazNJanssenRS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20:1447–50.
5.
KitahataMMGangeSJAbrahamAG. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med. 2009;360(18):1815–26.
6.
When to Start Consortium. Timing of initiation of antiretroviral therapy in AIDS-free HIV-1-infected patients: a collaborative analysis of 18 HIV cohort studies. Lancet. 2009;373(9672):1352–63.
7.
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Washington, DC: US Department of Health and Human Services; 2009. p 1–161.
8.
Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Morb Mortal Wkly Rep. 2006;55(RR14):1–17.
9.
WalenskyRPLosinaEMalatestaL. Effective HIV case identification through routine HIV screening at urgent care centers in Massachusetts. Am J Public Health. 2005;95(1):71–3.
10.
GoldenMRGiftTLBrewerDD. Peer referral for HIV case-finding among men who have sex with men. AIDS. 2006;20(15):1961–8.
11.
FarnhamPGHutchinsonABSansomSLBransonBM. Comparing the costs of HIV screening strategies and technologies in health-care settings. Public Health Rep. 2008;123(Suppl 3):51–62.
12.
SilvaAGlickNRLyssSB. Implementing an HIV and sexually transmitted disease screening program in an emergency department. Ann Emerg Med. 2007;49(5):564–72.
13.
MehtaSDHallJGreenwaldJICranstonKSkolnikPR. Patient risks, outcomes, and costs of voluntary HIV testing at five testing sites within a medical center. Public Health Rep. 2008;123:608–17.
14.
BogartLHowertonDLangeJ. Provider-related barriers to rapid HIV testing in US urban non-profit community clinics, community-based organizations (CBOs) and hospitals. AIDS Behav. 2010;14(3):697–707.
15.
ObermeyerCMOsbornM. The utilization of testing and counseling for HIV: a review of the social and behavioral evidence. Am J Public Health. 2007;97(10):1762–74.
16.
BogartLMHowertonDLangeJBeckerKSetodjiCMAschSM. Scope of rapid HIV testing in urban US hospitals. Public Health Rep. 2008;123:494–503.
17.
BogartLMHowertonDLangeJBeckerKSetodjiCMAschSM. Scope of rapid HIV testing in private nonprofit urban community health settings in the United States. Am J Public Health. 2008;98(4):736–42.
18.
HutchinsonABPatelPSansomSL. Cost-effectiveness of pooled nucleic acid amplification testing for acute HIV infection after third-generation HIV antibody screening and rapid testing in the United States: a comparison of three public health settings. PLoS Med. 2010;7(9):e1000342.
19.
HoltgraveDR. Costs and consequences of the US Centers for Disease Control and Prevention’s recommendations for opt-out HIV testing. PLoS Med. 2007;4(6):e194.
20.
SandersGDBayoumiAMSundaramV. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med. 2005;352:570–85.
21.
PaltielADWeinsteinMCKimmelAD. Expanded screening for HIV in the United States: an analysis of cost-effectiveness. N Engl J Med. 2005;352:586–95.
22.
PinkertonSDHoltgraveDR. A method for evaluating the economic efficiency of HIV behavioral risk reduction interventions. AIDS Behav. 1998;2(3):189–201.
23.
PinkertonSDJohnson-MasottiAPHoltgraveDRFarnhamPG. Using cost-effectiveness league tables to compare interventions to prevent sexual transmission of HIV. AIDS. 2001;15(7):917–28.
24.
PinkertonSDHoltgraveDRDiFranceiscoWJStevensonLYKellyJA. Cost-effectiveness of a community-level HIV risk reduction intervention. Am J Public Health. 1998;88(8):1239–42.
25.
ZaricGSBayoumiAMBrandeauMLOwensDK. The cost- effectiveness of counseling strategies to improve adherence to highly active antiretroviral therapy among men who have sex with men. Med Decis Making. 2008;28:359–76.
26.
PrabhuVSFarnhamPGHutchinsonAB. Cost-effectiveness of HIV screening in STD clinics, emergency departments, and inpatient units: a model-based analysis. PLoS ONE. 2011;6(5):e19936.
27.
UbelPAHirthRAChernewMEFendrickAM. What is the price of life and why doesn’t it increase at the rate of inflation?Arch Intern Med. 2003;163(14):1637–41.
28.
BraithwaiteRSMeltzerDOKingJTJrLeslieDRobertsMS. What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule?Med Care. 2008;46(4):349–56.
29.
WeinsteinMC. How much are Americans willing to pay for a quality-adjusted life year?Med Care. 2008;46(4):343–5.
30.
PinkertonSD. How many sexually-acquired HIV infections in the USA are due to acute-phase HIV transmission?AIDS. 2007;21:1625–9.
31.
PrabhuVSHutchinsonABFarnhamPGSansomSL. Sexually-acquired HIV infections in the USA due to acute-phase HIV transmission: an update. AIDS. 2009;23(13):1792–4.
32.
MarksGCrepazNSenterfittJWJanssenRS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005;39(4):446–53.
33.
GoldenMRSteklerJDWoodRW. Trends in the frequency of HIV testing and CD4 count at time of diagnosis among persons tested through a public health program: Seattle, Washington, 1995–2008. Montreal, Canada: Sixteenth Conference on Retroviruses and Opportunistic Infections; 2009.
34.
SchackmanBRGeboKAWalenskyRP. The lifetime cost of current human immunodeficiency virus care in the United States. Med Care. 2006;44(11):990–7.
35.
TengsTOLinTH. A meta-analysis of utility estimates for HIV/AIDS. Med Decis Making. 2002;22(6):475–81.
36.
Centers for Disease Control and Prevention. Prevalence and awareness of HIV infection among men who have sex with men: 21 cities, United States, 2008. MMWR Morb Mortal Wkly Rep. 2010;59(37):1201–7.
37.
Centers for Disease Control and Prevention. Results of the expanded HIV testing initiative: 25 jurisdictions, United States, 2007–2010. MMWR Morb Mortal Wkly Rep. 2011;60(24):805–10.
38.
HannaDBTsoiBWBegierEM. Most positive HIV Western blot tests do not diagnose new cases in New York City: implications for HIV testing programs. J Acquir Immune Defic Syndr. 2009;51(5):609–14.
39.
HoltgraveDRPinkertonSD. Updates of cost of illness and quality of life estimates for use in economic evaluations of HIV prevention programs. J Acquir Immune Defic Syndr. 1997;16(1):54–62.
40.
GoldMRSiegelJERussellLBWeinsteinMC, eds. Cost-Effectiveness in Health and Medicine. New York, NY: Oxford University Press; 1996.
41.
HutchinsonABBransonBMKimAFarnhamPG. A meta- analysis of the effectiveness of alternative HIV counseling and testing methods to increase knowledge of HIV status. AIDS. 2006;20(12):1597–604.
42.
PatelPKlausnerJDBaconOM. Detection of acute HIV infections in high-risk patients in California. J Acquir Immune Defic Syndr. 2006;42(1):75–9.
43.
Campos-OutcaltDMickeyTWeisbuchJJonesR. Integrating routine HIV testing into a public health STD clinic. Public Health Rep. 2006;121(2):175–80.
44.
PinkertonSDBogartLMHowertonDSnyderSBeckerKAschSM. Cost of rapid HIV testing at 45 US hospitals. AIDS Patient Care STDs. 2010;24(7):409–13.
45.
HelmsDJWeinstockHSMahleKC. HIV testing frequency among men who have sex with men attending sexually transmitted disease clinics: implications for HIV prevention and surveillance. J Acquir Immune Defic Syndr. 2009;50(3):320–6.
46.
LongEFBrandeauMLOwensDK. The cost-effectiveness and population outcomes of expanded HIV screening and antiretroviral treatment in the United States. Ann Intern Med. 2010;153(12):778–89.
47.
HsiehY-HJungJJShahanJB. Outcomes and cost analysis of 3 operational models for rapid HIV testing services in an academic inner-city emergency department. Ann Emerg Med. 2011;58(1)(Suppl 1):S133–9.
48.
HallHISongRRhodesP. Estimation of HIV Incidence in the United States. JAMA. 2008;300(5):520–9.
