Abstract
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.