title: Cost-effectiveness of HIV screening in STD clinics, emergency departments, and inpatient units: a model-based analysis.
abstract: BACKGROUND
  Identifying and treating persons with human immunodeficiency virus (HIV) infection early in their disease stage is considered an effective means of reducing the impact of the disease. We compared the cost-effectiveness of HIV screening in three settings, sexually transmitted disease (STD) clinics serving men who have sex with men, hospital emergency departments (EDs), settings where patients are likely to be diagnosed early, and inpatient diagnosis based on clinical manifestations.
  
  
  RESULTS
  We developed the Progression and Transmission of HIV/AIDS model, a health state transition model that tracks index patients and their infected partners from HIV infection to death. We used program characteristics for each setting to compare the incremental cost per quality-adjusted life year gained from early versus late diagnosis and treatment. We ran the model for 10,000 index patients for each setting, examining alternative scenarios, excluding and including transmission to partners, and assuming HAART was initiated at a CD4 count of either 350 or 500 cells/µL. Screening in STD clinics and EDs was cost-effective compared with diagnosing inpatients, even when including only the benefits to the index patients. Screening patients in STD clinics, who have less-advanced disease, was cost-effective compared with ED screening when treatment with HAART was initiated at a CD4 count of 500 cells/µL. When the benefits of reduced transmission to partners from early diagnosis were included, screening in settings with less-advanced disease stages was cost-saving compared with screening later in the course of infection. The study was limited by a small number of observations on CD4 count at diagnosis and by including transmission only to first generation partners of the index patients.
  
  
  CONCLUSIONS
  HIV prevention efforts can be advanced by screening in settings where patients present with less-advanced stages of HIV infection and by initiating treatment with HAART earlier in the course of infection.
authors.affiliation: Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Vimalanand S
authors.initials: VS
authors.lastname: Prabhu
authors.forename: Paul G
authors.initials: PG
authors.lastname: Farnham
authors.forename: Angela B
authors.initials: AB
authors.lastname: Hutchinson
authors.forename: Sada
authors.initials: S
authors.lastname: Soorapanth
authors.forename: James D
authors.initials: JD
authors.lastname: Heffelfinger
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Golden
authors.forename: John T
authors.initials: JT
authors.lastname: Brooks
authors.forename: David
authors.initials: D
authors.lastname: Rimland
authors.forename: Stephanie L
authors.initials: SL
authors.lastname: Sansom
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis; D004636:Emergency Service, Hospital / Q000191:economics*; D006678:HIV / Q000472:pathogenicity*; D015658:HIV Infections / Q000175:diagnosis / Q000191:economics* / Q000517:prevention & control; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data*; D008297:Male; D008403:Mass Screening; D015233:Models, Statistical; D019057:Quality-Adjusted Life Years; D012749:Sexually Transmitted Diseases / Q000175:diagnosis / Q000191:economics* / Q000517:prevention & control