Is Increased Screening and Early Antiretroviral Treatment for HIV-1 Worth the Investment?

An Analysis of the Public Health and Economic Impact of Improvement in the UK

AJ Brogan; SE Talbird; AE Davis; L Wild; D Flanagan


HIV Medicine. 2019;20(10):668-680. 

In This Article


Base-case Analysis

In each of the three population subgroups considered, the model estimated that increased HIV screening in SHS, followed by early treatment initiation, resulted in fewer onward HIV transmissions, more QALYs, and higher total costs (Table 3). With increased screening efforts that yielded 10% higher diagnosis rates, onward transmissions dropped by 3–5%, QALYs increased by 1–2%, and costs increased by 0.4–2.0%. More aggressive screening efforts that yielded a 50% increase in diagnosis rates resulted in 14–18% fewer onward transmissions, 3–7% more QALYs, and 1–8% higher costs. Cost increases were relatively modest compared with the associated benefits because lower costs to manage fewer secondary infections among partners partially offset higher costs in the initial cohort for screening, antiretroviral therapy (because of earlier treatment initiation), and other HIV-related clinical management costs (as individuals lived longer).

Incremental cost-effectiveness ratios (ICERs) associated with increased screening and early treatment initiation were nearly constant as various levels of increased screening (yielding 10%, 30%, and 50% improvement in diagnosis rates) were tested in each of the three subgroups (Table 3). ICERs for heterosexuals (about £22 000 per QALY gained) were within typical UK willingness-to-pay thresholds and were well below these thresholds for MSM (about £9500 per QALY gained) and PWID (about £6500 per QALY gained). For all subgroups, undiscounted ICERs were lower than discounted ICERs, and for PWID, increased screening dominated (i.e. had lower costs and more QALYs than) current screening in undiscounted results.

Sensitivity Analysis

Sensitivity analysis showed that model results were generally robust and were most sensitive to HIV infectivity before treatment initiation, test positivity rates with increased screening, the lifetime cost of a secondary HIV-1 infection, and, for MSM, the number of interactions with long-term partners (Table 4). ICERs increased for scenarios with lower HIV infectivity and lower positivity rates with increased screening, whereas increased screening dominated (i.e. had lower costs and more QALYs than) current screening in some scenarios testing higher HIV infectivity, higher lifetime costs for secondary infections, and more interactions with long-term partners. Results were less sensitive to the other scenarios tested, including alternate screening settings. ICERs remained consistent in settings with known, relatively high positivity rates (0.1–1.0%) but increased for the hypothetical scenario that assessed home testing with very low positivity (0.01%).