title: Routine HIV screening in Portugal: clinical impact and cost-effectiveness.
abstract: OBJECTIVE
  To compare the clinical outcomes and cost-effectiveness of routine HIV screening in Portugal to the current practice of targeted and on-demand screening.
  
  
  METHODS
  We used Portuguese national clinical and economic data to conduct a model-based assessment.
  
  
  METHODS
  We compared current HIV detection practices to strategies of increasingly frequent routine HIV screening in Portuguese adults aged 18-69. We considered several subpopulations and geographic regions with varying levels of undetected HIV prevalence and incidence. Baseline inputs for the national case included undiagnosed HIV prevalence 0.16%, annual incidence 0.03%, mean population age 43 years, mean CD4 count at care initiation 292 cells/μL, 63% HIV test acceptance, 78% linkage to care, and HIV rapid test cost €6 under the proposed routine screening program. Outcomes included quality-adjusted survival, secondary HIV transmission, cost, and incremental cost-effectiveness.
  
  
  RESULTS
  One-time national HIV screening increased HIV-infected survival from 164.09 quality-adjusted life months (QALMs) to 166.83 QALMs compared to current practice and had an incremental cost-effectiveness ratio (ICER) of €28,000 per quality-adjusted life year (QALY). Screening more frequently in higher-risk groups was cost-effective: for example screening annually in men who have sex with men or screening every three years in regions with higher incidence and prevalence produced ICERs of €21,000/QALY and €34,000/QALY, respectively.
  
  
  CONCLUSIONS
  One-time HIV screening in the Portuguese national population will increase survival and is cost-effective by international standards. More frequent screening in higher-risk regions and subpopulations is also justified. Given Portugal's challenging economic priorities, we recommend prioritizing screening in higher-risk populations and geographic settings.
authors.affiliation: Hôpital Bichat, Université Paris Diderot, Paris, France ; ATIP-Avenir Inserm: "Modélisation, Aide à la Décision, et Coût-Efficacité en Maladies Infectieuses," Inserm U1137, Université Denis Diderot, Paris, France.
authors.forename: Yazdan
authors.initials: Y
authors.lastname: Yazdanpanah
authors.affiliation: Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal.
authors.forename: Julian
authors.initials: J
authors.lastname: Perelman
authors.affiliation: Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America ; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
authors.forename: Madeline A
authors.initials: MA
authors.lastname: DiLorenzo
authors.affiliation: Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal.
authors.forename: Joana
authors.initials: J
authors.lastname: Alves
authors.affiliation: Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.
authors.forename: Henrique
authors.initials: H
authors.lastname: Barros
authors.affiliation: Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal.
authors.forename: Céu
authors.initials: C
authors.lastname: Mateus
authors.affiliation: Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal.
authors.forename: João
authors.initials: J
authors.lastname: Pereira
authors.affiliation: Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.
authors.forename: Kamal
authors.initials: K
authors.lastname: Mansinho
authors.affiliation: Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America ; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
authors.forename: Marion
authors.initials: M
authors.lastname: Robine
authors.affiliation: Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America ; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
authors.forename: Ji-Eun
authors.initials: JE
authors.lastname: Park
authors.affiliation: Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America ; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
authors.forename: Eric L
authors.initials: EL
authors.lastname: Ross
authors.affiliation: Harvard Medical School, Boston, Massachusetts, United States of America ; Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America ; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America ; Brigham and Women's Hospital, Boston, Massachusetts, United States of America ; Harvard Center for AIDS Research, Boston, Massachusetts, United States of America ; Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America.
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.affiliation: Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America ; Harvard Medical School, Boston, Massachusetts, United States of America ; Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America ; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America ; Brigham and Women's Hospital, Boston, Massachusetts, United States of America ; Harvard Center for AIDS Research, Boston, Massachusetts, United States of America.
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.affiliation: The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, United States of America ; Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts, United States of America.
authors.forename: Farzad
authors.initials: F
authors.lastname: Noubary
authors.affiliation: Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America ; Harvard Medical School, Boston, Massachusetts, United States of America ; Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America ; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, United States of America ; Harvard Center for AIDS Research, Boston, Massachusetts, United States of America ; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America.
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, United States of America.
authors.forename: A David
authors.initials: AD
authors.lastname: Paltiel
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003362:Cost-Benefit Analysis; D005260:Female; D015658:HIV Infections / Q000453:epidemiology*; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D011174:Portugal / Q000453:epidemiology; D015995:Prevalence; D012306:Risk; D055815:Young Adult