Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy.
BACKGROUND
The costs, benefits, and cost-effectiveness of screening for human immunodeficiency virus (HIV) in health care settings during the era of highly active antiretroviral therapy (HAART) have not been determined.


METHODS
We developed a Markov model of costs, quality of life, and survival associated with an HIV-screening program as compared with current practice. In both strategies, symptomatic patients were identified through symptom-based case finding. Identified patients started treatment when their CD4 count dropped to 350 cells per cubic millimeter. Disease progression was defined on the basis of CD4 levels and viral load. The likelihood of sexual transmission was based on viral load, knowledge of HIV status, and efficacy of counseling.


RESULTS
Given a 1 percent prevalence of unidentified HIV infection, screening increased life expectancy by 5.48 days, or 4.70 quality-adjusted days, at an estimated cost of 194 dollars per screened patient, for a cost-effectiveness ratio of 15,078 dollars per quality-adjusted life-year. Screening cost less than 50,000 dollars per quality-adjusted life-year if the prevalence of unidentified HIV infection exceeded 0.05 percent. Excluding HIV transmission, the cost-effectiveness of screening was 41,736 dollars per quality-adjusted life-year. Screening every five years, as compared with a one-time screening program, cost 57,138 dollars per quality-adjusted life-year, but was more attractive in settings with a high incidence of infection. Our results were sensitive to the efficacy of behavior modification, the benefit of early identification and therapy, and the prevalence and incidence of HIV infection.


CONCLUSIONS
The cost-effectiveness of routine HIV screening in health care settings, even in relatively low-prevalence populations, is similar to that of commonly accepted interventions, and such programs should be expanded.
Sanders
Gillian D
GD
Duke Clinical Research Institute, Duke University, Durham, NC 27715, USA. gillian.sanders@duke.edu
Bayoumi
Ahmed M
AM
Sundaram
Vandana
V
Bilir
S Pinar
SP
Neukermans
Christopher P
CP
Rydzak
Chara E
CE
Douglass
Lena R
LR
Lazzeroni
Laura C
LC
Holodniy
Mark
M
Owens
Douglas K
DK
D000328:Adult; D044966:Anti-Retroviral Agents / Q000191:economics; D023241:Antiretroviral Therapy, Highly Active / Q000191:economics; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D018450:Disease Progression; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000191:economics / Q000635:transmission; D017048:Health Care Costs; D006801:Humans; D008017:Life Expectancy; D008297:Male; D008390:Markov Chains; D008403:Mass Screening / Q000191:economics*; D015995:Prevalence; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D012307:Risk Factors
D044966:Anti-Retroviral Agents