The cost-effectiveness and population outcomes of expanded HIV screening and antiretroviral treatment in the United States.

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 × 10(9) 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.