title: Clinical impact and cost-effectiveness of expanded voluntary HIV testing in India.
abstract: BACKGROUND
  Despite expanding access to antiretroviral therapy (ART), most of the estimated 2.3 to 2.5 million HIV-infected individuals in India remain undiagnosed. The questions of whom to test for HIV and at what frequency remain unclear.
  
  
  METHODS
  We used a simulation model of HIV testing and treatment to examine alternative HIV screening strategies: 1) current practice, 2) one-time, 3) every five years, and 4) annually; and we applied these strategies to three population scenarios: 1) the general Indian population ("national population"), i.e. base case (HIV prevalence 0.29%; incidence 0.032/100 person-years [PY]); 2) high-prevalence districts (HIV prevalence 0.8%; incidence 0.088/100 PY), and 3) high-risk groups (HIV prevalence 5.0%; incidence 0.552/100 PY). Cohort characteristics reflected Indians reporting for HIV testing, with a median age of 35 years, 66% men, and a mean CD4 count of 305 cells/µl. The cost of a rapid HIV test was $3.33. Outcomes included life expectancy, HIV-related direct medical costs, incremental cost-effectiveness ratios (ICERs), and secondary transmission benefits. The threshold for "cost-effective" was defined as 3x the annual per capita GDP of India ($3,900/year of life saved [YLS]), or for "very cost-effective" was <1x the annual per capita GDP ($1,300/YLS).
  
  
  RESULTS
  Compared to current practice, one-time screening was very cost-effective in the national population (ICER: $1,100/YLS), high-prevalence districts (ICER: $800/YLS), and high-risk groups (ICER: $800/YLS). Screening every five years in the national population (ICER: $1,900/YLS) and annual screening in high-prevalence districts (ICER: $1,900/YLS) and high-risk groups (ICER: $1,800/YLS) were also cost-effective. Results were most sensitive to costs of care and linkage-to-care.
  
  
  CONCLUSIONS
  In India, voluntary HIV screening of the national population every five years offers substantial clinical benefit and is cost-effective. Annual screening is cost-effective among high-risk groups and in high-prevalence districts nationally. Routine HIV screening in India should be implemented.
authors.affiliation: Division of Infectious Disease, Department of Medicine, Alpert Medical School, Brown University/Miriam Hospital, Providence, Rhode Island, United States of America.
authors.forename: Kartik K
authors.initials: KK
authors.lastname: Venkatesh
authors.forename: Jessica E
authors.initials: JE
authors.lastname: Becker
authors.forename: Nagalingeswaran
authors.initials: N
authors.lastname: Kumarasamy
authors.forename: Yoriko M
authors.initials: YM
authors.lastname: Nakamura
authors.forename: Kenneth H
authors.initials: KH
authors.lastname: Mayer
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.forename: Soumya
authors.initials: S
authors.lastname: Swaminathan
authors.forename: Timothy P
authors.initials: TP
authors.lastname: Flanigan
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
mesh_terms: D000328:Adult; D018791:CD4 Lymphocyte Count; D003362:Cost-Benefit Analysis / Q000706:statistics & numerical data*; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000191:economics* / Q000453:epidemiology / Q000635:transmission; D006801:Humans; D007194:India / Q000453:epidemiology; D008017:Life Expectancy; D008297:Male; D008403:Mass Screening / Q000191:economics* / Q000379:methods; D015233:Models, Statistical; D015995:Prevalence; D012309:Risk-Taking