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

Ann Intern Med. 2010 Dec 21;153(12):778-89. doi: 10.7326/0003-4819-153-12-201012210-00004.


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.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Anti-Retroviral Agents / therapeutic use*
  • CD4 Lymphocyte Count
  • Cost-Benefit Analysis
  • Counseling
  • Diagnostic Errors
  • Epidemics*
  • HIV Infections / drug therapy*
  • HIV Infections / epidemiology
  • HIV Infections / prevention & control*
  • Humans
  • Incidence
  • Male
  • Mass Screening / economics*
  • Middle Aged
  • Models, Economic
  • Quality-Adjusted Life Years
  • Risk Reduction Behavior
  • United States / epidemiology
  • Young Adult


  • Anti-Retroviral Agents