The clinical impact and cost-effectiveness of routine, voluntary HIV screening in South Africa.
BACKGROUND
Although 900,000 HIV-infected South Africans receive antiretroviral therapy, the majority of South Africans with HIV remain undiagnosed.


METHODS
We use a published simulation model of HIV case detection and treatment to examine 3 HIV screening scenarios, in addition to current practice as follows: (1) one-time; (2) every 5 years; and (3) annually. South African model input data include the following: 16.9% HIV prevalence, 1.3% annual incidence, 49% test acceptance rate, HIV testing costs of $6.49/patient, and a 47% linkage-to-care rate (including 2 sequential antiretroviral therapy regimens) for identified cases. Outcomes include life expectancy, direct medical costs, and incremental cost-effectiveness.


RESULTS
HIV screening one-time, every 5 years, and annually increase HIV-infected quality-adjusted life expectancy (mean age 33 years) from 180.6 months (current practice) to 184.9, 187.6, and 197.2 months. The incremental cost-effectiveness of one-time screening is dominated by screening every 5 years. Screening every 5 years and annually each have incremental cost-effectiveness ratios of $1570/quality-adjusted life year and $1720/quality-adjusted life year. Screening annually is very cost-effective even in settings with the lowest incidence/prevalence, with test acceptance and linkage rates both as low as 20%, or when accounting for a stigma impact at least four-fold that of the base case.


CONCLUSIONS
In South Africa, annual voluntary HIV screening offers substantial clinical benefit and is very cost-effective, even with highly constrained access to care and treatment.
Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA. rwalensky@partners.org
Rochelle P
RP
Walensky
Robin
R
Wood
Mariam O
MO
Fofana
Neil A
NA
Martinson
Elena
E
Losina
Michael D
MD
April
Ingrid V
IV
Bassett
Bethany L
BL
Morris
Kenneth A
KA
Freedberg
A David
AD
Paltiel
D015492:AIDS Serodiagnosis / Q000191:economics* / Q000706:statistics & numerical data; D000328:Adult; D019380:Anti-HIV Agents / Q000191:economics / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D003955:Diagnostic Tests, Routine / Q000191:economics; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy / Q000191:economics / Q000401:mortality / Q000517:prevention & control; D006801:Humans; D008017:Life Expectancy; D008403:Mass Screening / Q000191:economics; D008962:Models, Theoretical; D057545:Social Stigma; D013019:South Africa / Q000453:epidemiology; D013997:Time Factors; D035141:Voluntary Programs / Q000191:economics
D019380:Anti-HIV Agents