• Elisa F Long, Margaret L Brandeau, and Douglas K Owens.
• Yale School of Management, New Haven, Connecticut 06520, USA. elisa.long@yale.edu
• Ann. Intern. Med. 2010 Dec 21; 153 (12): 778789778-89.

BackgroundAlthough 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.ObjectiveTo evaluate the effects on the U.S. HIV epidemic of expanded ART, HIV screening, or interventions to reduce risk behavior.DesignDynamic mathematical model of HIV transmission and disease progression and cost-effectiveness analysis.Data SourcesPublished literature.Target PopulationHigh-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 HorizonTwenty years and lifetime (costs and quality-adjusted life-years [QALYs]).PerspectiveSocietal.InterventionExpanded HIV screening and counseling, treatment with ART, or both.Outcome MeasuresNew HIV infections, discounted costs and QALYs, and incremental cost-effectiveness ratios.Results Of Base Case AnalysisOne-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 AnalysisWith 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%.LimitationThe model of disease progression and treatment was simplified, and acute HIV screening was excluded.ConclusionExpanding 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 SourceNational Institute on Drug Abuse, National Institutes of Health, and Department of Veterans Affairs.

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