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

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Background

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 ≥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.

Methods

We performed a cost-effectiveness analysis using a computer simulation model of HIV screening and disease as applied to inpatients in U.S. hospitals.

Results

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 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 per QALY gained. Increasing counseling and testing costs from $53 to $103 per person still yielded a cost-effectiveness ratio below $100 000 per QALY gained at a prevalence of undiagnosed infection of 0.1%.

Conclusion

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.

Section snippets

Study overview

We constructed an inpatient screening model (hereafter referred to as the “screening module”), building upon the foundation of a previously designed and published model of the natural history and treatment of HIV disease (hereafter referred to as the “disease model”).14, 15, 16 The purpose of the screening module is to simulate the detection of HIV infection in a general inpatient target group, with a specified prevalence of undetected HIV infection, whose members are offered routine voluntary

Base case

A routine inpatient HIV screening program increased projected, discounted life expectancy from 5602.56 to 6215.15 QALYs per 1000 HIV-infected patients, or approximately 7.35 quality-adjusted life-months per infected person (Table 2). At a 37% test acceptance rate, screening of 1000 uninfected patients on average cost $19,800, or approximately $20 per uninfected person. By advancing the time of identification with screening, the mean CD4 cell count at detection was increased from 196 to 244

Discussion

The 2001 CDC guidelines for HIV counseling, testing, and referral recommend routine screening of all inpatients in hospitals with an HIV prevalence of 1%.3 This threshold is largely based on a single-blinded HIV seroprevalence study of 20 acute care U.S. hospitals conducted by Janssen et al. in 1992.4 In that study, hospitals with AIDS diagnosis rates of >1/1000 discharges correlated to HIV seroprevalence rates of >1%. The authors estimated that a routine inpatient HIV screening program in

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  • Cited by (0)

    This research was funded by the National Institute of Allergy and Infectious Diseases (K23AI01794, K24AI062476, K25AI50436, R01AI42006, Center for AIDS Research P30AI42851), the National Institute of Mental Health (R01MH65869), the National Institute on Drug Abuse (R01DA015612), and the Centers for Disease Control and Prevention (S1396-20/21).

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