Expanded screening for HIV in the United States - An analysis of cost-effectiveness

被引:435
作者
Paltiel, AD
Weinstein, MC
Kimmel, AD
Seage, GR
Losina, E
Zhang, H
Freedberg, KA
Walensky, RP
机构
[1] Yale Univ, Sch Med, Dept Epidemiol & Publ Hlth, New Haven, CT 06520 USA
[2] Harvard Univ, Sch Publ Hlth, Dept Hlth Policy & Management, Ctr Risk Anal, Boston, MA 02115 USA
[3] Harvard Univ, Massachusetts Gen Hosp, Sch Med, Div Infect Dis, Boston, MA USA
[4] Harvard Univ, Massachusetts Gen Hosp, Sch Med, Div Gen Med, Boston, MA USA
[5] Harvard Univ, Massachusetts Gen Hosp, Sch Med, Partners AIDS Res Ctr,Dept Med, Boston, MA USA
[6] Harvard Univ, Sch Publ Hlth, Dept Epidemiol, Boston, MA 02115 USA
[7] Boston Univ, Sch Publ Hlth, Dept Biostat, Boston, MA USA
[8] Boston Univ, Sch Publ Hlth, Dept Epidemiol, Boston, MA USA
[9] Brigham & Womens Hosp, Dept Med, Div Infect Dis, Boston, MA 02115 USA
关键词
D O I
10.1056/NEJMsa042088
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
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.
引用
收藏
页码:586 / 595
页数:10
相关论文
共 36 条
[1]  
[Anonymous], STAT ABSTR US
[2]   A randomized study of antiretroviral management based on plasma genotypic antiretroviral resistance testing in patients failing therapy [J].
Baxter, JD ;
Mayers, DL ;
Wentworth, DN ;
Neaton, JD ;
Hoover, ML ;
Winters, MA ;
Mannheimer, SB ;
Thompson, MA ;
Abrams, DI ;
Brizz, BJ ;
Ioannidis, JPA ;
Merigan, TC .
AIDS, 2000, 14 (09) :F83-F93
[3]   Routine HIV screening of sexually transmitted disease clinic attenders has favourable cost-effectiveness ratio in low HIV prevalence settings [J].
Bos, JM ;
van der Meijden, WI ;
Swart, W ;
Postma, MJ .
AIDS, 2002, 16 (08) :1185-1187
[4]   The care of HIV-infected adults in the United States [J].
Bozzette, SA ;
Berry, SH ;
Duan, NJ ;
Frankel, MR ;
Leibowitz, AA ;
Lefkowitz, D ;
Emmons, CA ;
Senterfitt, JW ;
Berk, ML ;
Morton, SC ;
Shapiro, MF .
NEW ENGLAND JOURNAL OF MEDICINE, 1998, 339 (26) :1897-1904
[5]  
CAMPSMITH M, 2001, 2001 NAT HIV PREV C
[6]  
CDC, 2001, Morbidity and Mortality Weekly Report, V50, P1
[7]  
*CDCP, HIV AIDS UPD GLANC H
[8]  
Centers for Disease Control and Prevention (CDC), 2003, MMWR Morb Mortal Wkly Rep, V52, P329
[9]  
Centers for Disease Control and Prevention (CDC), 2002, MMWR Morb Mortal Wkly Rep, V51, P1051
[10]  
*DEP HLTH HUM SERV, GUID US ANT AG HIV I