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Previous Volume 352:586-595 February 10, 2005 Number 6 Next

	Full Text PDF PDA Full Text Supplementary Material Editorial by Bozzette, S. A. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear PubMed Citation

ABSTRACT

Background Although the Centers for Disease Control and Prevention (CDC) recommend routine HIV counseling, testing, and referral (HIVCTR) in settings with at least a 1 percent prevalence of HIV, roughly 280,000 Americans are unaware of their human immunodeficiency virus (HIV) infection. The effect of expanded screening for HIV is unknown in the era of effective antiretroviral therapy.

Methods We developed a computer simulation model of HIV screening and treatment to compare routine, voluntary HIVCTR with current practice in three target populations: "high-risk" (3.0 percent prevalence of undiagnosed HIV infection; 1.2 percent annual incidence); "CDC threshold" (1.0 percent and 0.12 percent, respectively); and "U.S. general" (0.1 percent and 0.01 percent). Input data were derived from clinical trials and observational cohorts. Outcomes included quality-adjusted survival, cost, and cost-effectiveness.

Results In the high-risk population, the addition of one-time screening for HIV antibodies with an enzyme-linked immunosorbent assay (ELISA) to current practice was associated with earlier diagnosis of HIV (mean CD4 cell count at diagnosis, 210 vs. 154 per cubic millimeter). One-time screening also improved average survival time among HIV-infected patients (quality-adjusted survival, 220.7 months vs. 219.8 months). The incremental cost-effectiveness was $36,000 per quality-adjusted life-year gained. Testing every five years cost $50,000 per quality-adjusted life-year gained, and testing every three years cost $63,000 per quality-adjusted life-year gained. In the CDC threshold population, the cost-effectiveness ratio for one-time screening with ELISA was $38,000 per quality-adjusted life-year gained, whereas testing every five years cost $71,000 per quality-adjusted life-year gained, and testing every three years cost $85,000 per quality-adjusted life-year gained. In the U.S. general population, one-time screening cost $113,000 per quality-adjusted life-year gained.

Conclusions In all but the lowest-risk populations, routine, voluntary screening for HIV once every three to five years is justified on both clinical and cost-effectiveness grounds. One-time screening in the general population may also be cost-effective.

Source Information

From the Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, Conn. (A.D.P.); and the Center for Risk Analysis, Department of Health Policy and Management, Harvard School of Public Health (M.C.W., K.A.F.), the Divisions of Infectious Disease and General Medicine and the Partners AIDS Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School (A.D.K., H.Z., K.A.F., R.P.W.), the Department of Epidemiology, Harvard School of Public Health (G.R.S.), the Departments of Biostatistics and Epidemiology, Boston University School of Public Health (E.L., K.A.F.), and the Division of Infectious Disease, Department of Medicine, Brigham and Women's Hospital (R.P.W.) — all in Boston.

Address reprint requests to Dr. Paltiel at the Department of Epidemiology and Public Health, Yale School of Medicine, 60 College St., New Haven, CT 06520-8034, or at david.paltiel{at}yale.edu.

Full Text of this Article

Related Letters:

Cost-Effectiveness of Screening for HIV
Taiwo B. O., Thrasher A. D., Ford C. L., Nearing K. A., da Silveira E., Sanders G. D., Bayoumi A. M., Owens D. K., Paltiel A. D., Walensky R. P., Freedberg K. A.
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N Engl J Med 2005; 352:2137-2139, May 19, 2005. Correspondence

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