title: The cost-effectiveness and population outcomes of expanded HIV screening and antiretroviral treatment in the United States.
abstract: BACKGROUND
  Although recent guidelines call for expanded routine screening for HIV, resources for antiretroviral therapy (ART) are limited, and all eligible persons are not currently receiving treatment.
  
  
  OBJECTIVE
  To evaluate the effects on the U.S. HIV epidemic of expanded ART, HIV screening, or interventions to reduce risk behavior.
  
  
  METHODS
  Dynamic mathematical model of HIV transmission and disease progression and cost-effectiveness analysis.
  
  
  METHODS
  Published literature.
  
  
  METHODS
  High-risk (injection drug users and men who have sex with men) and low-risk persons aged 15 to 64 years in the United States.
  
  
  METHODS
  Twenty years and lifetime (costs and quality-adjusted life-years [QALYs]).
  
  
  CONCLUSIONS
  Societal.
  
  
  METHODS
  Expanded HIV screening and counseling, treatment with ART, or both.
  
  
  METHODS
  New HIV infections, discounted costs and QALYs, and incremental cost-effectiveness ratios.
  
  
  RESULTS
  One-time HIV screening of low-risk persons coupled with annual screening of high-risk persons could prevent 6.7% of a projected 1.23 million new infections and cost $22,382 per QALY gained, assuming a 20% reduction in sexual activity after screening. Expanding ART utilization to 75% of eligible persons prevents 10.3% of infections and costs $20,300 per QALY gained. A combination strategy prevents 17.3% of infections and costs $21,580 per QALY gained.
  
  
  RESULTS
  With no reduction in sexual activity, expanded screening prevents 3.7% of infections. Earlier ART initiation when a CD4 count is greater than 0.350 × 10(9) cells/L prevents 20% to 28% of infections. Additional efforts to halve high-risk behavior could reduce infections by 65%.
  
  
  CONCLUSIONS
  The model of disease progression and treatment was simplified, and acute HIV screening was excluded.
  
  
  CONCLUSIONS
  Expanding HIV screening and treatment simultaneously offers the greatest health benefit and is cost-effective. However, even substantial expansion of HIV screening and treatment programs is not sufficient to markedly reduce the U.S. HIV epidemic without substantial reductions in risk behavior.
  
  
  BACKGROUND
  National Institute on Drug Abuse, National Institutes of Health, and Department of Veterans Affairs.
authors.affiliation: Yale School of Management, New Haven, Connecticut 06520, USA. elisa.long@yale.edu
authors.forename: Elisa F
authors.initials: EF
authors.lastname: Long
authors.forename: Margaret L
authors.initials: ML
authors.lastname: Brandeau
authors.forename: Douglas K
authors.initials: DK
authors.lastname: Owens
mesh_terms: D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D003362:Cost-Benefit Analysis; D003376:Counseling; D003951:Diagnostic Errors; D058872:Epidemics; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000517:prevention & control*; D006801:Humans; D015994:Incidence; D008297:Male; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D018803:Models, Economic; D019057:Quality-Adjusted Life Years; D040242:Risk Reduction Behavior; D014481:United States / Q000453:epidemiology; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents