Routine human immunodeficiency virus testing: An economic evaluation of current guidelines

Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, and the Partners AIDS Research Center, Harvard Medical School, Boston, Massachusetts 02114, USA.
The American Journal of Medicine (Impact Factor: 5). 04/2005; 118(3):292-300. DOI: 10.1016/j.amjmed.2004.07.055
Source: PubMed


The Centers for Disease Control and Prevention guidelines recommend human immunodeficiency virus (HIV) counseling, testing, and referral for all patients in hospitals with an HIV prevalence of >or=1%. The 1% screening threshold has not been critically examined since HIV became effectively treatable in 1995. Our objective was to evaluate the clinical effect and cost-effectiveness of current guidelines and of alternate HIV prevalence thresholds.
We performed a cost-effectiveness analysis using a computer simulation model of HIV screening and disease as applied to inpatients in U.S. hospitals.
At an undiagnosed inpatient HIV prevalence of 1% and an overall participation rate of 33%, HIV screening increased mean quality-adjusted life expectancy by 6.13 years per 1000 inpatients, with a cost-effectiveness ratio of 35,400 dollars per quality-adjusted life-year (QALY) gained. Expansion of screening to settings with a prevalence as low as 0.1% increased the ratio to 64,500 dollars per QALY gained. Increasing counseling and testing costs from 53 dollars to 103 dollars per person still yielded a cost-effectiveness ratio below 100,000 dollars per QALY gained at a prevalence of undiagnosed infection of 0.1%.
Routine inpatient HIV screening programs are not only cost-effective but would likely remain so at a prevalence of undiagnosed HIV infection 10 times lower than recommended thresholds. The current HIV counseling, testing, and referral guidelines should now be implemented nationwide as a way of linking infected patients to life-sustaining care.

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    • "HTC is very important in efforts to ensure universal access to prevention and timely HIV treatment and care services. Previous studies have shown that HTC could be cost-effective and could increase the life expectancy of individuals with HIV [6] and it is a key factor in the PMTCT. It also provides clients the opportunity to confidentially learn of the HIV status, which is a gateway to accessing treatment [7,8]. "
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    • "It is anticipated that a substantial number of individuals identifying earlier with lower CD4 counts through this wider testing process will successfully engage in care, receive cART, decrease their infectivity (and the rate of secondary infections), and improve their own health. The costs of wider testing and the increased use of cART may be defrayed by decreasing the substantial and sustained direct medical costs from later presentation, the indirect costs to family from an avoidable illness (i.e., presentation with HIV/AIDS), and the opportunity costs to society by minimising lost productivity and reducing secondary infections [42, 43]. "
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    • "Both patient-and provider-initiated VCT can be provided at substance use treatment sites (Grusky et al., 2006; Gunn et al., 2005; Lally et al., 2005). There is increasing evidence, however, that opt-out, provider-initiated HIV testing may be more effective at identifying cases of HIV and has been demonstrated to be cost effective (Paltiel et al., 2005; Walensky et al., 2005). In settings where testing facilities are limited, providing HIV screening as well as screening for other infectious diseases (e.g., hepatitis B and C) at health clinics and rehabilitation programmes for drug users is one way to target individuals at greatest risk. "
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