title: Routine human immunodeficiency virus testing: an economic evaluation of current guidelines.
abstract: BACKGROUND
  The Centers for Disease Control and Prevention guidelines recommend human immunodeficiency virus (HIV) counseling, testing, and referral for all patients in hospitals with an HIV prevalence of >or=1%. The 1% screening threshold has not been critically examined since HIV became effectively treatable in 1995. Our objective was to evaluate the clinical effect and cost-effectiveness of current guidelines and of alternate HIV prevalence thresholds.
  
  
  METHODS
  We performed a cost-effectiveness analysis using a computer simulation model of HIV screening and disease as applied to inpatients in U.S. hospitals.
  
  
  RESULTS
  At an undiagnosed inpatient HIV prevalence of 1% and an overall participation rate of 33%, HIV screening increased mean quality-adjusted life expectancy by 6.13 years per 1000 inpatients, with a cost-effectiveness ratio of 35,400 dollars per quality-adjusted life-year (QALY) gained. Expansion of screening to settings with a prevalence as low as 0.1% increased the ratio to 64,500 dollars per QALY gained. Increasing counseling and testing costs from 53 dollars to 103 dollars per person still yielded a cost-effectiveness ratio below 100,000 dollars per QALY gained at a prevalence of undiagnosed infection of 0.1%.
  
  
  CONCLUSIONS
  Routine inpatient HIV screening programs are not only cost-effective but would likely remain so at a prevalence of undiagnosed HIV infection 10 times lower than recommended thresholds. The current HIV counseling, testing, and referral guidelines should now be implemented nationwide as a way of linking infected patients to life-sustaining care.
authors.affiliation: Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, and the Partners AIDS Research Center, Harvard Medical School, Boston, Massachusetts 02114, USA. rwalensky@partners.org
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.forename: Milton C
authors.initials: MC
authors.lastname: Weinstein
authors.forename: April D
authors.initials: AD
authors.lastname: Kimmel
authors.forename: George R
authors.initials: GR
authors.lastname: Seage
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.forename: Paul E
authors.initials: PE
authors.lastname: Sax
authors.forename: Hong
authors.initials: H
authors.lastname: Zhang
authors.forename: Heather E
authors.initials: HE
authors.lastname: Smith
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.forename: A David
authors.initials: AD
authors.lastname: Paltiel
mesh_terms: D002487:Centers for Disease Control and Prevention, U.S. / Q000592:standards; D003362:Cost-Benefit Analysis; D005260:Female; D017408:Guidelines as Topic; D006678:HIV / Q000302:isolation & purification*; D015658:HIV Infections / Q000175:diagnosis* / Q000401:mortality; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D012680:Sensitivity and Specificity; D014481:United States / Q000453:epidemiology