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The Cost-Effectiveness and Population Outcomes of Expanded HIV Screening and Antiretroviral Treatment in the United States

Elisa F. Long, PhD; Margaret L. Brandeau, PhD; and Douglas K. Owens, MD, MS
[+] Article, Author, and Disclosure Information

From the Yale School of Management, New Haven, Connecticut; Stanford University, Stanford, California; and Veterans Affairs Palo Alto Health Care System, Palo Alto, California.

Grant Support: By the National Institute on Drug Abuse, National Institutes of Health (R-01-DA-15612), and Department of Veterans Affairs.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-0968.

Reproducible Research Statement:Study protocol and data set: Not available. Statistical code: Additional details may be available by contacting Dr. Long (e-mail, elisa.long@yale.edu), although the exact code is not available in the public domain.

Requests for Single Reprints: Elisa F. Long, PhD, Yale School of Management, 135 Prospect Street, New Haven, CT 06520; e-mail, elisa.long@yale.edu.

Current Author Addresses: Dr. Long: Yale School of Management, 135 Prospect Street, New Haven, CT 06520.

Dr. Brandeau: Department of Management Science and Engineering, Stanford University, 262 Huang Engineering Center, Stanford, CA 94305.

Dr. Owens: Center for Primary Care and Outcomes Research, Stanford University, 117 Encina Commons, Stanford, CA 94305.

Author Contributions: Conception and design: E.F. Long, M.L. Brandeau, D.K. Owens.

Analysis and interpretation of the data: E.F. Long, M.L. Brandeau.

Drafting of the article: E.F. Long.

Critical revision of the article for important intellectual content: E.F. Long, M.L. Brandeau, D.K. Owens.

Final approval of the article: E.F. Long, M.L. Brandeau, D.K. Owens.

Obtaining of funding: M.L. Brandeau, D.K. Owens.

Collection and assembly of data: E.F. Long.

Ann Intern Med. 2010;153(12):778-789. doi:10.7326/0003-4819-153-12-201012210-00004
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Background: Although recent guidelines call for expanded routine screening for HIV, resources for antiretroviral therapy (ART) are limited, and all eligible persons are not currently receiving treatment.

Objective: To evaluate the effects on the U.S. HIV epidemic of expanded ART, HIV screening, or interventions to reduce risk behavior.

Design: Dynamic mathematical model of HIV transmission and disease progression and cost-effectiveness analysis.

Data Sources: Published literature.

Target Population: High-risk (injection drug users and men who have sex with men) and low-risk persons aged 15 to 64 years in the United States.

Time Horizon: Twenty years and lifetime (costs and quality-adjusted life-years [QALYs]).

Perspective: Societal.

Intervention: Expanded HIV screening and counseling, treatment with ART, or both.

Outcome Measures: New HIV infections, discounted costs and QALYs, and incremental cost-effectiveness ratios.

Results of Base-Case Analysis: One-time HIV screening of low-risk persons coupled with annual screening of high-risk persons could prevent 6.7% of a projected 1.23 million new infections and cost $22 382 per QALY gained, assuming a 20% reduction in sexual activity after screening. Expanding ART utilization to 75% of eligible persons prevents 10.3% of infections and costs $20 300 per QALY gained. A combination strategy prevents 17.3% of infections and costs $21 580 per QALY gained.

Results of Sensitivity Analysis: With no reduction in sexual activity, expanded screening prevents 3.7% of infections. Earlier ART initiation when a CD4 count is greater than 0.350 × 109 cells/L prevents 20% to 28% of infections. Additional efforts to halve high-risk behavior could reduce infections by 65%.

Limitation: The model of disease progression and treatment was simplified, and acute HIV screening was excluded.

Conclusion: Expanding HIV screening and treatment simultaneously offers the greatest health benefit and is cost-effective. However, even substantial expansion of HIV screening and treatment programs is not sufficient to markedly reduce the U.S. HIV epidemic without substantial reductions in risk behavior.

Primary Funding Source: National Institute on Drug Abuse, National Institutes of Health, and Department of Veterans Affairs.


Grahic Jump Location
Figure 1.
Complementary effects of expanded HIV screening and treatment.

The x-axis displays varying levels of HIV screening (current, every 3 y, every 2 y, or annually). The y-axis displays ART utilization levels (50%, 60%, 70%, 80%, or 90%). The curves are isocontours showing a given number (and fraction) of HIV infections prevented over 20 y compared with the status quo. The point at the origin corresponds to current screening and treatment levels. HIV screening reduces sexual behavior by 20% among persons identified as HIV-positive, and ART reduces sexual infectivity by 90%. Under the status quo, an estimated 1.23 million HIV infections occur over 20 years. ART = antiretroviral therapy.

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Grahic Jump Location
Figure 2.
Cost-effectiveness of alternative screening and treatment strategies.

Incremental costs and QALYs of expanded HIV screening and counseling, expanded access to ART, or a combination of screening and ART. Expanded screening occurs once, annually, or every 3 y. Expanded ART includes treatment utilization of 75%. The cost-effectiveness frontier (solid line) includes strategies that may be cost-effective if the incremental cost-effectiveness ratio is less than the accepted threshold. Strategies that are not on the frontier are dominated, meaning that they are not an efficient use of resources. Costs and QALYs are calculated over a 20-y time horizon and are discounted to the present. ART = antiretroviral therapy; QALY = quality-adjusted life-year.

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Grahic Jump Location
Figure 3.
Fraction of HIV infections prevented with varying HIV screening effectiveness.

Each bar corresponds to the fraction of HIV infections prevented over 20 y, with varying degrees of screening effectiveness by reducing sexual partners among persons identified as HIV-positive (base case, 20%). The benefits from starting ART earlier are due to infected persons who are identified through a screening program and can initiate treatment, thereby reducing their infectivity. The benefits from reduced behavior result from reduced sexual partnerships among persons identified as HIV-positive (and hence reduced HIV transmission) after screening and counseling. Expanded screening occurs once for low-risk persons and annually for high-risk persons. Expanded ART includes treatment utilization of 75%. Under the status quo, an estimated 1.23 million HIV infections occur over 20 y. ART = antiretroviral therapy.

Grahic Jump Location




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